(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "U.S. Navy Medicine Vol. 70, No. 4 April 1979"

VADM Wfflarf P. Arentzen, MC, USN 
Surgeon General of the Navy 

RADM H.A. Sparks, MC, USN 
Deputy Surgeon General 



Director of Public Affairs 

ENS Richard A. Schmidt, USNR 

Editor 

Jan Kenneth Herman 

Assistant Editor 

Virginia M. Novinski 

Editorial Assistant 

Nancy R. Keesee 



Contributing Editors 
Contributing Editor-in-Chief- CDR E.L, 
Taylor (MC); Aerospace Medicine: CAPT 
M.G, Webb (MC); Dental Corps. CAPT R.D. 
Ulrey (DC): Education: LT R.E. Btibb (MSC); 
Fleet Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT DO. Castell (MC); 
Hospital Corps: HMCM H.A, Olszak; Legal: 
LCDR R.E. Broach (JAGC); Marine Corps: 
CAPT D.R. Hauler (MC); Medical Service 
Corps: CAPT P.D. Nelson (MSC): Nephrol- 
ogy: CDR J.D. Wallin (MC); Nurse Corps: 
CAPT M.F. Halt (NC); Occupational Medi- 
cine: CDR J.J, Bellanca (MC); Preventive 
Medicine: CAPT D.F. Hoeffler (MC); Re- 
search: CAPT J. P. Bloom (MC); Submarine 
Medicine: CAPT R.L. Sphar (MC) 



POLJCV: V 5 Navy Medicine is to official publkasni 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery. It disseminates to Navy Medical 
Department personnel official and professional information 
relative to medicine, dentistry, and the allied health sci- 
ences Optntorts ettpresaetj are those of the authors arid do 
not necessarily represent Ibe official position of the Depart- 
ment of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery. Although L'.S. Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department personnel via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental. Medical Service 
and Nurse Corps officer: one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE; All correspondence should be 
addressed to: Editor. VS. Navy Medicine. Department of 
the Navy. Bureau of Medicine and Surgery (Code 0010). 
Washington. DC. 20172. Telephone: (Area Code 202) 254- 
«2S3. 2$4-431f>, 2S4-U14: Auiovon 2»M2S3. 294-OI6. 294- 
4214. Contributions from the field are welcome and will be 
published as space permits, subject to editing and possible 
abridgment. 

The issuance of this publication is approved in accordance 
with Department of the Navy Publications and Printing 
Regulations (NAVEXOS P-J51. 

NAVMED P-S088 



U.S.NAVY 




Vol. 70, No. 4 
April 1979 



1 From the Surgeon General 

2 Department Rounds 

Ken Koskella: One of the Navy's Flying Doctors . . . Three Picked 
for Flag Rank 

6 Notes and Announcements 

9 Scholars' Scuttlebutt 

Servicemen's and Veterans Group Life Insurance 

10 Independent Duty — Update 

A Profile of Viral Hepatitis 
CDR W.M. Parsons, MSC, USN 

12 Features 

John Paul Jones: A Twentieth Century Post Mortem 

15 Use of Facsimile Transmitters for a Clinical Pharmacy Program 
LCDR P.T. Riley, MSC, USN 
LTD. DePolo, Jr., MSC, USN 
LTJG C.L. Hall, Jr., MSC, USNR 

18 The Origins of BUMED Audiovisual Training 
K. W. Hammel 

23 Professional 

Emotional Problems After Therapeutic Abortion 
CDRJ.O. Cavenar, Jr., MC, USNR-R 
G.J. O'Shanick, M.D. 
R.J. Taska. M.D. 

26 A Critical Look at Margin Placement in Restorative Dentistry 
LTB.W. Winterholler, DC, USNR 

29 BUMED SITREP 



COVER: A.S. Conrad portrait of John Paul Jones. An autopsy con- 
ducted in 1905 helped verify the naval hero's remains 113 years after 
his death. 




From the Surqeon General 



Public Affairs — An All 
Hands Evolution 



Over the past year, this nation 
has been involved in a significant 
public debate on the roles and mis- 
sions of the U.S. Navy. That debate 
has spilled over from the halls of 
Congress, where such things are 
commonplace, into the mainstream 
of public discussion, which is un- 
usual. 

The debate has to a large extent 
been stimulated by an increased 
awareness of this nation's depend- 
ency upon sea power and the con- 
stantly growing capability of the 
Soviet Navy to present a threat to 
American maritime supremacy. The 
questions are: do we need a Navy, 
and if so, what kind of a Navy do we 
need? 

As the discussion has widened, 
more and more people of disparate 
views are expressing themselves. 
Often these individuals are not 
knowledgeable of the real issue, or 
they are advocates of specific 
narrow solutions to the Navy's 
broad problems. Such persons often 
attract attention, even though their 
enthusiasm may exceed their facts, 
because there is a vacuum of infor- 
mation concerning the Navy's views 



in some areas and in parts of our 
society. 

It is this apparent vacuum which 
should concern us as Navy profes- 
sionals. If we do not speak for the 
Navy, who will? The task cannot be 
left solely to the Secretary of the 
Navy, the CNO, myself on your be- 
half, or the public affairs commu- 
nity. I believe it is incumbent upon 
all of us to be aware of the issues, 
gain information concerning leader- 
ship's views and the reason for 
those views, and to be prepared to 
discuss them intelligently in any 
forum — especially with our own 
subordinates and those outside the 
Navy we contact on a personal 
basis. 

There are several places you can 
derive the information necessary to 
speak on the issues. The first 
sources should be the recent CNO 
and SECNAV posture statements 
to Congress. CHINFO "Policy 
Briefs," issued monthly, the weekly 
message "Newsgram," and the 
"Currents" section of All Hands 
magazine also cover subjects of 
interest for all naval personnel. 
More detailed information on spe- 



cific personnel, weapons, or mate- 
riel policies can be obtained from 
my office or CHINFO. I urge you to 
take advantage of both the facilities 
and opportunities which are avail- 
able to you to enhance your knowl- 
edge of our Navy. 

Because the sums of money in- 
volved in capital programs like ship- 
building and aircraft procurement, 
and in personnel programs are so 
large, and because the implementa- 
tion of successful programs has 
such a potential impact on national 
security, you should anticipate con- 
cerned interest by the civilian 
health care professionals in your 
community. Be prepared to take 
advantage of your access to profes- 
sional societies, and your own credi- 
bility as a trusted colleague to tell 
the Navy's story. It is in the 
citizen's interest that our public 
affairs effort be an all hands evolu- 
tion. 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 
United States Navy 



Volume 70, April 1979 



Department Rounds 



Ken Koskella: One of the Navy's 
Flying Doctors 



Anyone meeting Navy LCDR Ken 
Koskella, MC, USN, for the first 
time might well be confused by the 
appearance of his uniform. He is 
one of an elite corps of only 10 naval 
officers who wear both the gold 
wings of the naval aviator and the 
acorn oak leaf of the Navy medical 
doctor. 

Inevitably nicknamed "Doc," Ken 
Koskella and the other nine Navy 
doctors work under the Dual Desig- 
nator Program, which allows flight 
surgeons to go through the same 
flight training as other naval avia- 
tors, earning their pilot wings and 
being assigned to fly Navy planes 
on a regular basis. 

LCDR Koskella is presently as- 
signed to Attack Squadron 128 (VA- 
128) at Whidbey Island Naval Air 
Station, Oak Harbor, Washington, 
where he performs the dual role of 



flight surgeon and flight instructor 
for the replacement air wing train- 
ing squadron. 

He began his naval career 
with an NROTC scholarship at the 
University of Idaho in 1965, after 
graduating from Ben Lomond High 
School in Ogden, Utah. When he 
decided to switch to a premed 
major, the scholarship was can- 
celled. However, after earning his 
bachelor's degree, he entered 
another Navy program called the 
1965 Medical-Osteopathic Scholar- 
ship Program which placed him on 
active duty status while he studied 
to become a doctor at Washington 
Medical School in St. Louis, Mo. At 
this time he was commissioned and 
started drawing pay as a regular 
Navy officer. 

While attending medical school, 
Dr. Koskella and a group of friends 




As he pores over his aircraft book, Koskella gets ready to log some flight time 



took up flying as a hobby. Between 
medical classes he took flying 
lessions and eventually bought his 
own Beechcraft airplane. Because 
of his interest in flying, "Doc" 
began to look at the role of a Navy 
flight surgeon, and decided to apply 
for the program. 

After graduating from medical 
school and serving a year of intern- 
ship at Oakland Naval Hospital, 
Ken Koskella got his chance to go to 
flight surgeon school. The school is 
held at Naval Aerospace Medical 
Institute in Pensacola, Fla., and 
lasts six months, consisting of four 
months academic study and two 
months of flight school with Train- 
ing Squadron One (VT-1). 

Dr. Koskella served the next two 
years as flight surgeon with RVAH- 
3 at Key West, Fla. While there he 
heard about the dual designator 
program and voiced an interest in it 
to BUMED. Having met all the re- 
quirements, he was sent to addi- 
tional flight training at VT-9 and 
VT-7 in Meridian, Miss. After earn- 
ing his pilot wings, the physician- 
aviator was ordered to Whidbey 
Island and VA-128 last August to 
serve as an instructor for fleet re- 
placement aviators and as the 
squadron flight surgeon. 

Koskella stands regular duty one 
night a week and two weekends a 
month, besides spending two days a 
week treating patients at the Whid- 
bey Island Naval Hospital. Still he is 
expected by BUMED to log at least 
1,000 jet flight hours before moving 
on to another duty station. This 



U.S. Navy Medicine 



number is required for "Doc" to be 
eligible for Test Pilot School in 
Patuxent River, Md., a very good 
assignment. He now has about 400 
jet hours and will need to average 
30 hours a month during his stay at 
Whidbey to achieve the 1,000-hour 
mark. 

An interesting feature of the 
"flying doc" program is that he 
and his mates will probably not be 
called upon to go on cruise. The pur- 
pose of the dual designator program 
is to enable flight surgeons to better 
understand the problems aviators 
encounter while flying so the acci- 
dent rate may be reduced. Since 
doctors are not allowed to bear 
arms, according to the Geneva Con- 
vention, the greatest need for dual 
designator officers is at home in the 
training and research areas. 

At Test Pilot School, or other 
naval air test facilities, duties 
Koskella may be expected to under- 
take are in the areas of designing 
flight gear, cockpit design, escape 
systems on aircraft, and aircrew 
survival. The specialized knowledge 
and experience he has as a doctor 
and pilot are invaluable to the Navy, 
the only branch of the armed forces 
that employs the dual designator 
program. His qualifications are also 
desirable for possible work in the 
space program and on accident 
review boards. Dr. Koskella is a 
member of the accident review 
board in VA-128. 

Koskella explained that the dual 
designator program has been in 
existence for about 20 years, start- 
ing out with only three billets and 
gradually increasing to the 10 billets 
now available. The program could 
be stopped at any time by Congress. 
With a tight defense budget, he is 
afraid the program may be cut back. 




LCDR Koskella ... in the cockpit of an A-6E Intruder and 
patients 



treating one of his 




If it is, "Doc" will go back to being 
a regular flight surgeon and will 
turn to civilian aviation to keep up 
his flying interest. 

Eventually, Dr. Koskella wants to 
get into family medicine but at pre- 
sent he lacks the two years resi- 
dency needed. In the future he will 



probably return to McCall, Idaho, 
where his parents live, and set up 
practice. For now, he's doing the 
three things he enjoys most: flying, 
practicing medicine, and spending 
time with his wife and children. 

— Story by Brenda Lundy 



Volume 70, April 1979 



Three Picked for Flag Rank 



The Medical Department has 
three new flag officers — one each 
from the Medical, Dental, and 
Nurse Corps. 

RADM-selectee Clinton Hershey 
Lowery (MC), director of Clinical 
Services, Naval Regional Medical 
Center, Charleston, S.C. since 
1977, was born 10 April 1929 in 
Pittsburgh, Pa. He attended the 
University of Pittsburgh and re- 
ceived his M.D. degree in 1955. 

Dr. Lowery interned at St. John's 
General Hospital, Pittsburgh, Pa. 
and then entered the Navy in 1956. 
After a tour as general medical 
officer, Destroyer Division 282, he 
began a residency in general sur- 
gery at the Naval Hospital, Ports- 
mouth, Va. in 1958. He served at 
the Naval Regional Medical Centers 
Camp Lejuene, N.C, Portsmouth, 
Va., Camp Pendleton, Calif., and 
Charleston, S.C. 

He also served as executive offi- 
cer and then commanding officer of 
the First Medical Battalion, Repub- 
lic of Vietnam, 1967-1968. 

Dr. Lowery is a diplomate of the 
American College of Surgeons. He 




CAPT Lowery 



was appointed associate clinical 
professor of surgery, Medical Uni- 
versity of South Carolina in 1975. 

In addition to the Legion of Merit 
with Combat V and the Meritorious 
Service Medal, Dr. Lowery holds 
the Presidential Unit Citation, First 
Marine Division Combat Action 
Medal, Vietnam Service Medal, 
Vietnamese Cross of Gallantry, 
Vietnam Campaign Medal, and 
National Defense Medal. 

RADM-selectee James D. Enoch 

(DC), head, Planning and Logistics 
Branch of the Dental Division, 
BUMED, was born in 1927 in Nash- 
ville, Tenn. He graduated from 
Vanderbilt University with a B.A. 
degree in business administration 
and the University of Tennessee 
with a D.D.S. degree. He also com- 
pleted the course in general post- 
graduate dentistry at the Naval 
Dental School and received the M.S. 
degree from the University of 
Michigan in the field of operative 
dentistry. 

Dr. Enoch began his military 
career in 1945 as an apprentice sea- 
man. As pharmacist mate third 
class, he served as ward corpsman 
and operating room technician at 
the Naval Hospital, Memphis, 
Tenn. Upon release from active 
duty, he began his college educa- 
tion and subsequently returned to 
active duty in 1957 following three 
years of private dental practice. 

Dr. Enoch has had tours of duty 
at the Marine Corps Recruit Depot, 
Parris Island, S.C, Marine Corps 
Base, Camp Lejuene, N.C, aboard 
the USS Essex homeported in May- 
port, Fla. and Quonset Point, R.I., 
and as a member of the staff of the 
Naval Dental School, with additional 
duty to the White House as the 
dentist to the President. He also 




CAPT Enoch 



served as senior dental officer at the 
Naval Station, San Juan, Puerto 
Rico prior to reporting to the Naval 
Administrative Command, Naval 
Training Center, Great Lakes, 111. In 
1974 Dr. Enoch became command- 
ing officer, Naval Regional Dental 
Center, Great Lakes with additional 
duties as director of Dental Activi- 
ties, 9th Naval District and Dental 
Reserve Program officer, 9th Naval 
District. He reported to BUMED in 
April 1976. 

Dr. Enoch is a fellow of the Amer- 
ican College of Dentists, a fellow of 
the Internationa] College of Den- 
tists, a member of the Academy of 
Operative Dentistry, Academy of 
Gold Foil Operators, the American 
Dental Association, Association of 
Military Surgeons of the United 
States, and an associate member of 
the Chicago Dental Society. 

Dr. Enoch holds the Navy Com- 
mendation Medal, Navy Expedi- 
tionary Medal, American Campaign 
Medal, World War II Victory Med- 
al, and American Theater Medal. 

RADM-selectee Frances T. Shea 

(NC), chief, Nursing Service, Naval 
Regional Medical Center, San Diego 
was born 26 Feb 1929 in Chicopee, 



U.S. Navy Medicine 



Mass. She graduated from St. 
Joseph College, Hartford, Conn, 
with a B.S. degree. She also holds 
an M.S. degree from De Paul Uni- 
versity, Chicago, 111. 

CAPT Shea was commissioned in 
1951 and has held staff nurse posi- 
tions at the Naval Hospitals in 
Portsmouth, Va., St. Albans, N.Y., 
Rota, Spain, and Chelsea, Mass. 
She also served as Nurse Recruiting 
Programs Officer in Richmond, Va., 
operating room supervisor aboard 
the USS Repose, and chief of the 
Nursing Service at the National 
Naval Medical Center, Bethesda, 
Md. 

CAPT Shea is a member of the 
Association of Operating Room 
Nurses and the San Diego Directors 
of Nursing Council. She holds the 
Meritorious Service Medal, Navy 
Commendation, Navy Unit Com- 
mendation, National Defense Medal 
with one star, Vietnam Campaign 
with four stars, Armed Forces Re- 
serve Medal, Republic of Vietnam 
Service Medal, Vietnamese Cross of 
Gallantry, and the Vietnamese Civil 
Action Medal. 

As of 1 July 1979, RADM-selectee 
Shea will be transferred to BUMED, 
Washington, D.C. and will serve as 
the director of the Nurse Corps. 




CAPT Shea 

Volume 70, April 1979 



Winners of BUMED's Energy 
Conservation Competition 



Three medical facilities have been selected as winners of the 
BUMED Energy Conservation Award. As such, these activities 
will represent BUMED in the Navy-wide competition for the Secre- 
tary of the Navy's Energy Conservation Award. Representing BU- 
MED in the Large Shore Activities category is the Naval Regional 
Medical Center, Jacksonville, and Naval Regional Medical Center, 
Camp Pendleton. Representing the Small Shore Activities 
category is the Naval Regional Medical Center, Corpus Christi, 

The competition centers around five functional areas. 

• Awareness of and compliance with existing directives and 
issuances in the field of energy resource management. 

• Planning in the areas of energy conservation and use of less 
depleting, more available energy sources. 

• Efficient use and maintenance of all energy consuming, 
producing, and distributing equipment. 

• Innovative proposals for the improvement of existing equip- 
ment, or the design and development of a new process or unit to 
solve specific problems of energy production, utilization, or distri- 
bution. 

• Training of personnel in specific duties and responsibilities 
related to energy conservation as well as awareness of the com- 
mand's specific problems in energy conservation. 

Of course the dominant feature for selection of these activities is 
the excellent job they have been doing in reducing energy con- 
sumption. 

Copies of the winning entries will be provided to those activities 
who request them. If you think your activity can do better, enter 
the Awards Program next year and prove it! information and 
assistance can be obtained by contacting the BUMED Facilities 
Division. 

Honorable mention goes to the Naval Aerospace Medical Cen- 
ter. Pensacola. To the activities who entered the program but were 
not selected, we thank you, compliment you on a job well done, 
and ask you to try again next year. 

Again, congratulations to the Naval Regional Medical Center, 
Jacksonville, the Naval Regional Medical Center, Camp Pendle- 
ton, and the Naval Regional Medical Center, Corpus Christi. 



Notes & Announcements 



IN MEMORIAM 

CDR Robert J. Walker III, USN (Ret.), who served in 
two wars, died 19 Jan 1979 at age 85. 

CDR Walker was born in Washington, D.C., and was 
a grandson of Robert John Walker, Secretary of the 
Treasury during the Polk administration. He was a 1916 
graduate of the U.S. Military Academy. 

During World War I, CDR Walker served on the 
battleship Utah. He attended the Naval Post Graduate 
School and Columbia University, where he received a 
master's degree in electrical engineering in 1923. 
Later, he became commander of the Pope and Mine 
Division 3 of the Atlantic Fleet. 

CDR Walker retired in 1937 and worked for the 
Diesel Engine Division of General Motors until he was 
recalled to active duty in 1941. During World War II, 
his work involved machine tools required by naval ship- 
yards dealing with wartime repairs. 



NURSE CORPS CONTINUING EDUCATION 

The Nurse Corps Continuing Education Approval and 
Recognition Program (CEARP), administered by the 
Naval Health Sciences Education and Training Com- 
mand, Bethesda, Md., approved 32 Category I courses 
this quarter. The sponsors, courses and contact hours 
are listed below. 

NRMC Orlando, Fla. 32813 
Toxemia of Pregnancy (1.5) 
Nursing Audit (6) 

NRMC Great Lakes, III. 60088 
Middle Management (6) 
Nursing Grand Rounds (Crohn's Disease) (2.5) 



Learning from Autopsies (2) 

Acute Leukemia (2) 

Physical Assessment of the Abdomen, Thorax and 

Lungs (2) 
Adolescent Pregnancies (2) 
Continuing Education: Your Responsibility (2) 
Pediatric Respiratory Emergencies (2) 
Looking into Officer Fitness Reports, Assertiveness, 

Self-Evaluation and Delegation (4) 

NRMC Charleston, S. C. 29408 

Physical Assessment of Chest and Thorax (4) 

NRMC Philadelphia. Pa. 19145 
CPR — Basic Rescuer's Course (6) 

NNMC Bethesda, Md. 20014 

Theories and Methods of Nursing Intervention in 
Self-Destructive Behavior (7) 

A Personalized System of Instruction in Total Paren- 
teral Nutrition (40) 

NH Beaufort, S.C. 29902 

I.V. Medication Certification Program for RN's and 

PA's (4) 

U.S. NRMC Guam, FPO San Francisco 96630 
Diabetic Teaching Program (2) 

U.S. NRMC Okinawa, FPO Seattle 98778 

Gram-Negative Sepsis (2) 

Facial Fractures and Developmental Jaw Deform- 
ity (2) 

Interpretation of Lab Data: A Case Study Approach 
(2) 



NRMC Newport, R.I. 02840 
Nursing and the Law (2) 

NRMC Portsmouth, Va. 23708 

Alcoholism Orientation Workshop (60) 



U.S. NH Roosevelt Roads, Puerto Rico, FPO New York 
09551 

Medical/Nursing Management of Jaundice in the 
Newborn (2) 

Basic Life Support (6) 



NRMC Pensacola, Fla. 32512 

CPR — Basic Rescuer's Course (6) 



US. NH Rota, Spain, FPO New York 09540 
Overview of Clinical Cardiology (16) 



NRMC Jacksonville, Ha. 32214 

Advanced Cardiac Life Support — Provider 
Course (16) 



U.S. NH Guantanamo Bay, Cuba, FPO New York 09593 
Caring for the Patient with a Cerebral Aneurysm (2) 
Hemodialysis (2) 



6 



U.S. Navy Medicine 



Navy Environmental Health Center, 3333 Vine, Cincin- 
nati. Ohio 45220 

Principles and Concepts of Occupational Health: 

Their Practical Application (12) 
Advanced Cardiac Life Support (16) 
Office of Workmen's Compensation Program and 
Civil Service Procedures (6.5) 



SPIROMETRY TESTING 

There will be an intensive training course in Spirome- 
try Testing 7-8 June 1979. The course is offered for 
physicians, nurses, and technicians, and will include 
practical instruction in the pulmonary function labora- 
tory, as well as lecture sessions. The lectures will pro- 
vide a working knowledge of the instruments, their 
maintenance, calibration, test procedures, and the 
existing and proposed spirometer standards. The 
course has been approved by the AM A for Category I 
credit and CEU's for technicians. There will be a $250 
fee with enrollment limited to 20 registrants. 

For further information contact: Program Coordina- 
tor, Continuing Education, The Johns Hopkins Univer- 
sity, Turner 22, 720 Ruthland Ave., Baltimore, Md. 
21205. Telephone (301) 955-5880. 



UNIVERSITY OF CALIFORNIA COURSES 

The Department of Extended Programs in Medical 
Education at the University of California School of 
Medicine will offer the following courses: 

Tropical Diseases in the United States 25-26 May 1979 

The course is designed for the general practitioner, 
internist, and pediatrician who must diagnose and treat 
many perplexing tropical diseases in returning travel- 
ers, immigrants, Peace Corps workers, and others. 
Emphasis will be on disease commonly seen plus 
several diseases, often considered tropical, that are 
also endemic to the United States. The course is also 
designed to aide the practicing physician in those 
instances when he may be called upon to advise pa- 
tients on immunizations and chemoprophylaxis in ad- 
vance of travel to or life in the tropics. The program is 
approved for Category I credit of the Physician's Recog- 
nition Award of the American Medical Association and 
the California Medical Association. 



Advances in Internal Medicine 4-8 June 1979 

Designed to provide an intensive, broad review in in- 
ternal medicine for the internist in practice and the 
candidate for certification by the American Board of 
Medicine. 

Practical Topics in Pediatric Gastroenterology and 
Nutrition 18-20 June 1979 

For more information write or call: Extended Pro- 
grams in Medical Education, University of California, 
Room 569-U, Third and Parnassus Ave., San Francisco, 
Calif. 94143. Telephone (415) 666-4251. 



SCIENTIFIC EXPERIMENTS 

The Massachusetts Institute of Technology will offer 
a course in Design and Analysis of Scientific Experi- 
ments 25-30 June 1979. Applications will be made to 
the physical, chemical, biological, medical, engineer- 
ing, and industrial sciences, and to experimentation in 
psychology and economics. 

Further details may be obtained by writing to the 
Director of the Summer Session, Room E19-356, Mas- 
sachusetts Institute of Technology, Cambridge, Mass. 
02139. 



AEROSPACE MEDICAL ASSOCIATION'S GOLDEN 
ANNIVERSARY 

The 50th anniversary of the Aerospace Medical Asso- 
ciation will be celebrated 14-17 May at the Sheraton- 
Park Hotel in Washington, D.C. This annual scientific 
meeting will provide a diverse forum for physicians in 
almost all clinical specialties. Dr. Robert Benford, an 
association member, indicates that in conjunction with 
this meeting, plans are underway by the National Air 
and Space Museum of the Smithsonian to present a 
special exhibit depicting the advances made in aviation 
and space medicine during the last 50 years. 

The publication of a book, Man in Flight: Biomedical 
Achievements in Aerospace by Eloise Engel and Arnold 
Lott, is scheduled to coincide with the meeting. Dr. 
Benford is writing the prologue and a special pre-publi- 
cation price of $13.95 is offered to AMA members. 
Further information may be obtained by writing AMA, 
Washington National Airport, Washington, D.C. 20001. 



Volume 70, April 1979 



OBSTETRICS AND GYNECOLOGY MEETING 

The 28th Annual Armed Forces Seminar on Obstet- 
rics and Gynecology and the 18th Annual Meeting of 
the Armed Forces District of the American College of 
Obstetricians and Gynecologists will be held 30 Sept-5 
Oct 1979 at the Convention Center, San Antonio, Tex. 

Postgraduate courses for physicians are planned in 
oncology, maternal fetal medicine, endocrinology, 
pathology, gynecology, and obstetric and gynecologic 
infections. Four postgraduate courses for nurse practi- 
tioners, nurse midwives, and staff nurses are planned 
in obstetric, neonatal, and gynecologic problems as 
well as infection control. 

Deadline dates for submission of papers for the 
scientific sessions will be 1 May 1979 for a paper 
abstract and 1 July 1979 for a completed manuscript. 

For further information contact: COL Robert E. 
Harris, USAF, MC, Program Chairman, AFD-ACOG 
'79, CMR #8. Box 8385, Wilford Hall USAF Medical 
Center, Lackland AFB, Tex. 78236. Telephone: Com- 
mercial (512) 671-7846, Autovon 473-7846. 



American Board of Internal Medicine 
CDR George H. Barbier, MC, USNR 

(Pulmonary Disease) 
LCDR Robert B. Daggett, MC, USNR 
LCDR Sudha M. Praba, MC, USNR 

American Board of Obstetrics and Gynecology 
LCDR Alan L. Gorrell, MC, USN 
LCDR Richard C. Miller, MC, USNR 
LCDR Walter F. Moreano, MC, USNR 
LCDR John W. Seeds, MC, USNR 

American Board of Orthopaedic Surgery 
LCDR James W. McLeod, MC, USN 

American Board of Otolaryngology 
LCDR William R. Bond, Jr., MC, USNR 
LCDR Michael B. Nolph, MC, USNR 

American Board of Pathology 
LCDR Lily K. Lapointe, MC, USNR 
LCDR David M. Kerr, MC, USNR 



AMERICAN BOARD CERTIFICATIONS 

(Subspecialties are indicated in parentheses) 

American Board of Dermatology 

LT Richard J. Hilder, Jr., MC, USNR 

American Board of Family Practice 
LCDR Farouk B. Asaad, MC, USN 
LCDR William F. Bina HI, MC, USN 
LCDR Darrell R, Dixon, MC, USNR 
LCDR Johnny R. Glenn, MC, USNR 
LCDR John R. Horn, MC, USNR 
LCDR Robert C. Patton, MC, USNR 
LCDR Calvin L. Polland, MC, USN 
LCDR Donald G. Urban, MC, USNR 
LCDR Fred N. Ozawa, MC, USNR 
LT Michael D. Crowley, MC, USNR 
LT Elizabeth H. Edmunds, MC, USNR 
LT Randell J. Hartlage, MC, USNR 
LT James N. Icken, MC, USNR 
LT Joe S. Johnson, MC, USN 
LT Dennis P. Kimbleton, MC, USNR 
LT John D. Lentz III, MC, USNR 
LT Paul A. McLeod, MC, USNR 
LT John P. Michel, MC, USNR 
LT William I. Miller, MC, USNR 
LT Jeffrey H. Perlson, MC, USNR 
LT Van J. Stitt, Jr., MC, USNR 
LT Frank S. Wignall, MC, USNR 
LT David B. Young, MC, USNR 



American Board of Pediatrics 
LCDR Walter D. Ashe, MC, USNR 
LCDR John W. McReynolds, MC, USN 
LT Douglas G. Burnette, Jr., MC, USNR 

American Board of Preventive Medicine 

CDR Walter C. Hulon, MC, USN (Aerospace Medicine) 

American Board of Psychiatry 
LCDR Mark D. Lenger, MC, USNR 

American Board of Radiology 
LT Devchand V. Patel, MC, USN 

American Board of Surgery 
LCDR Miles H. Mason III, MC, USNR 
LCDR Charles W. Schwab, MC, USN 
LCDR Richard A. Steliga, MC, USNR 

American College of Preventive Medicine 
CDR Michael Stek, Jr., MC, USN 



NEW EDITOR SEEKS ARTICLES AND PHOTOS 

U.S. Navy Medicine has always encouraged our 
readers to submit articles in the areas of their expertise 
or experience. We especially are looking for good black 
and white glossy photos to go along with those submis- 
sions. (8 X 10 size is best but 5 X 7's are also accepta- 
ble). If you have a manuscript and you also happen to 
be good with a camera, we'd like to hear from you. 



8 



U.S. Navy Medicine 



Scholars' Scuttlebutt 



Servicemen's and Veterans 
Group Life Insurance 



Servicemen's Group Life Insurance (SGLI) offers mil- 
itary personnel up to $20,000 of group coverage, term 
life insurance, with no cash, loan, paid-up, or extended 
insurance value. The $3.40 monthly premium for this 
coverage is automatically deducted from your pay- 
check. 

You may decline SGLI coverage, or you may reduce 
your coverage to $15,000, $10,000 or $5,000 with corre- 
sponding reductions in premiums to $2.55, $1.70 and 
$0.85. 

To decline or reduce SGLI coverage, you must fill out 
VA Form 29-8286 and file it with the disbursing officer 
at your active duty or active- duty-for training (ACDU- 
TRA) station. 

Members of the Naval Reserve who report to 
ACDUTRA for more than 30 days automatically receive 
the $20,000 SGLI coverage. Since Armed Forces Health 
Professions Scholarship Program students are required 
by law to spend 45 days each year on ACDUTRA, they 
are automatically covered under SGLI during their 
ACDUTRA tour and 120 days beyond. Naval Reserve 
students in other programs, such as the Dental Student 
19251 Program, are also eligible if their ACDUTRA 
lasts more than 30 days. 

After release from ACDUTRA, your SGLI coverage 
continues for 120 days without any premium charge. 
You may then extend your coverage by converting to 
Veterans Group Life Insurance (VGLI). The amount of 
coverage and the premiums are the same as SGLI, but 
the method of premium payment is different; also, the 
length of participation is limited to five years and is 
nonrenewable. 

Students cannot apply for VGLI unless they were 
previously insured under SGLI. Also, the VGLI policy 
cannot be for an amount greater than the SGLI cover- 
age. After release from ACDUTRA, you will have 120 
days to convert to VGLI without evidence of insurabil- 
ity. Once these 120 days have elapsed, you have an 
additional year in which to apply for VGLI, but evidence 
of insurability may be required. 

HOW TO APPLY FOR VGLI 

Within 120 days of release from ACDUTRA: 

1) Obtain VA Form 29-8714 (Application for Veter- 
ans Group Life Insurance) from any VA office or from 
OSGLI, 212 Washington St., Newark, N.J. 07102. 

Volume 70, April 1979 



Reprinted from February 1978 

2) Mail the complete VA form along with a fully en- 
dorsed copy of your ACDUTRA orders and $3.40 to 
OSGLI. Upon approval of your application, OSGLI will 
send you a certificate and supply of monthly premium 
payment cards. Your subsequent monthly payments 
will not come due until one month after the 120-day 
"free premium" period. Arrangements may also be 
made to pay quarterly, semiannually, or annually. 

Within one year after 120 days have elapsed: 

1) Obtain VA Form 29-8714-2 {Application for Veter- 
ans Group Life Insurance — Veterans Separated More 
Than 120 Days) from any VA office or from OSGLI. 

2) Follow the same instructions given above. The 
basic difference between the two forms is inclusion of a 
health information section on VA 29-8714-2. OSGLI 
may also request additional medical information or fur- 
ther proof of insurability if warranted by your answers 
in the health information section. 

FUTURE ACDUTRA AND ACTIVE DUTY 

Although you may carry both VGLI and SGLI, the 
combined amount of coverage cannot exceed $20,000. 
When you report for each tour of ACDUTRA, you are 
again automatically covered under SGLI and $3.40 per 
month will be deducted from your pay. If you wish to 
stop this deduction, upon reporting for ACDUTRA you 
must immediately decline SGLI in writing on VA Form 
29-8286. Either the personnel office or the disbursing 
office at your ACDUTRA station will have this form. 

You may not cancel your VGLI to take advantage of 
the 120-day SGLI "free premium" period each time you 
report for ACDUTRA. However, once you report for 
extended active duty after graduation, you should 
cancel your VGLI policy and take SGLI coverage. You 
will again become eligible for the VGLI five-year non- 
renewable policy after your release from active duty. 



i >m t a 



Independent Duty — Update 



A Profile of Viral Hepatitis 



CDR W.M. Parsons, MSC, USN 



The liver is one of the vital organs in the human 
body. It functions in part to cleanse the blood of foreign 
substances and serves to prevent excessive accumula- 
tion of certain body wastes to toxic levels. The liver 
further serves to detoxify, or neutralize, foreign chemi- 
cal substances which may enter the bloodstream. 
Should normal functioning of this organ become upset 
due to disease or injury, serious consequences to the 
individual may result requiring long-term treatment 
and convalescence. In the case of shipboard personnel, 
liver disease can effectively remove a person from a 
duty status for a considerable period and sometimes 
permanently. 

Inflammatory liver disease may be classified under 
the single term "hepatitis." Hepatitis may have a num- 
ber of causes, including bacterial infections, certain 
parasitic infections, drug or chemical toxicity including 
alcoholism, biliary duct obstructions, and viral infec- 
tions. The causative agents which offer the greatest 
potential for widespread infection among shipboard 
personnel are of viral origin. 

The Infectious Agent. Current research into viral 
hepatitis has identified three types of viruses which 
may cause the disease. The disease is clinically similar, 
but the viral agents differ in behavior and epidemiol- 
ogy. The three types of viral hepatitis are hepatitis A, 
caused by hepatitis type A virus (HAV), hepatitis type 
B, caused by hepatitis type B virus (HBV), and non-A, 
non-B hepatitis, caused by "other hepatitis viruses." 
Hepatitis A and B were formerly known as infectious 
hepatitis and serum hepatitis respectively, and account 
for most cases of viral hepatitis. 

The Disease. Hepatitis A is characterized by an 
abrupt onset after a 15-45 day (average 25-30 days) in- 
cubation period. Fever, malaise, anorexia, nausea, 



From the Department of the Navy, Bureau of Medicine and 
Surgery (Code 551J). Washington. D.C. 20372. 



abdominal discomfort, jaundice, and dark urine are 
generally present. A frank distaste for smoking is often 
noted in patients who smoke. Serum glutamic oxalo- 
acetic transaminases (SGOT) may be characteristically 
elevated. 

Hepatitis B follows a similar clinical pattern, but with 
a characteristically longer incubation period of 60-180 
days (average 90 days). 

Transmission. Hepatitis A is transmitted primarily 
via the fecal-oral route in situations of poor sanitation 
and/or close contact with infected persons. Common 
source transmission through contaminated food or 
water can occur, and is of major importance in a poten- 
tial outbreak aboard ship. HAV is present in the feces 
of infected persons, with peak viral excretion occurring 
during the latter part of the incubation period, before 
symptoms occur. A food-handler incubating hepatitis 
A, therefore, could conceivably pass the disease to 
virtually every crewman, with those at greatest risk 
being the handler's closest contacts. Hepatitis A may 
be acquired while ashore on liberty or leave via the 
consumption of contaminated raw foods such as salad 
type greens, water, and more frequently, raw shellfish 
such as clams, oysters, or fish. Shipboard personnel 
must be intensely educated to the high risk of acquiring 
hepatitis A and cautioned against consuming raw foods 
in foreign ports. Recently, several outbreaks of hepati- 
tis A have been attributed to contamination of needles 
and syringes with subsequent parenteral inoculation of 
the organism into the body. 

Hepatitis B may be acquired from several sources 
including accidental inoculation by contaminated 
needles; infusion of contaminated whole blood or 
plasma; through serum contaminated skin cuts or 
abrasions; introduction of contaminated serum or 
plasma via hands into the mouth or eyes; infective 
secretions such as saliva or semen into mucosal sur- 
faces through sexual contact; indirect transmission of 
contaminated serum, plasma, or blood via vectors or 



10 



U.S. Navy Medicine 



inanimate environmental surfaces. Transmission via 
the gastrointestinal route does not occur. 

Prophylaxis. Prophylaxis is directed against hepatitis 
A through the use of an immunizing dose of immune 
serum globulin, and is regulated by BUMED1NST 
6230.13 series. Prophylaxis procedures are based on 
whether there is a pre- or post-exposure situation. Pre- 
exposure prophylaxis is instituted when it is anticipated 
that exposure would be unavoidable, particularly in 
areas in which the prevalence of hepatitis A is high. 
Immunization with 5.0 ml immune serum globulin may 
be required when temporary additional duty in Korea, 
Cambodia, Indonesia, Laos, Singapore, Malaysia, 
Hong Kong, or Thailand is anticipated. In other areas, 
each port should be evaluated as to disease prevalence. 
Normally, immune serum globulin is not administered 
to personnel going ashore in a liberty or leave status 
unless there is a frank outbreak of hepatitis in the port- 
of-call. In this instance, cancellation of the port visit is 
recommended. 

Post-exposure prophylaxis is required when one or 
more cases of hepatitis A occur among the crew. Pro- 
phylaxis may be limited to intimate contacts such as 
compartment mates, close working associates, or fre- 
quent liberty companions. Aboard ship, the situation 
may occur where the index case occurs in a food han- 
dler. This situation must be closely evaluated by the 
ship's medical department representative, with, if 
possible, assistance from an NRMC Preventive Medi- 
cine Service or Environmental and Preventive Medicine 
Unit. 

If it is determined that disease could have been trans- 
mitted to the crew through food preparation and han- 
dling operations, a mass immune serum globulin pro- 
phylaxis program may be necessary. If at all possible, 
positive identification of the hepatitis A virus should be 
made prior to instituting such a mass program. It is 
recognized, however, that at sea such a clinical con- 
firmation may not be possible, and in this case the final 
decision must be based on individual circumstances 
and is best made by the local command. It is recom- 
mended that, when possible, technical assistance and 
advice be sought from the nearest Environmental and 
Preventive Medicine Unit. 

Emergency procurement of immune serum globulin 
can be made through submission of a priority message 
MILSTRIP requisition to DPSC, Philadelphia (SGM), or 



by requesting via telephone (215) 952-2111, Autovon 
444-2111 to Customer Service, Directorate of Medical 
Materiel, DPSC. 

Dosages. Hepatitis A contacts should receive .01 ml 
immune serum globulin per pound of body weight up to 
a maximum of 2 ml. Effectiveness lasts for approxi- 
mately one month. 

Reports. Cases of Hepatitis A, B, or non-A, non-B 
should be reported in accordance with BUMEDINST 
6220.3 series, Disease Alert Reports. 

Patient Management. The patient with viral hepati- 
tis, as noted previously, presents a manifestation of 
body discomfort, muscular and/or abdominal pain, 
nausea and vomiting, marked loss of appetite, and 
generalized weakness. During the acute phase of the 
disease, bed rest may be required. Beyond the acute 
phase, however, bed rest is not normally warranted, 
but return to normal activity in keeping with the pa- 
tient's assigned duties should be gradual and in accord- 
ance with the return of patient appetite and stamina. 
Patient's should avoid vigorous physical activity and 
any consumption of alcohol. Hepatotoxic drugs should 
not be administered. The time for complete recovery 
ranges from 3 to 16 weeks. Depending on the opera- 
tional situation, assistance or technical advice should 
be requested from the nearest medical officer. 

Needles, syringes, lancets, and blood-collecting 
equipment, as well as stools and urine of hepatitis 
patients should be considered as contaminated. Such 
equipment should be handled with extreme care in 
order to prevent transmission of the disease to medical 
personnel. 



References 

1. Recommendation of the Public Health Service Advisory Com- 
mittee on Immunization Practices — Immune Globulins for Protection 
Against Viral Hepatitis. USDHEW, PHS, CDC, Atlanta, Ga. 

2. Sartwell PE (ed): MaxcyRosenau Preventive Medicine and 
Public Health. New York, Appleton-Century Crofts, 1973. 

3. Horsfall FL, Tamm I: Viral and Rickettsia! Infections of Man. 
Philadelphia, JB Lippincott Co, 1965. 

4. Krupp MA, Chatton MJ: Current Diagnosis and Treatment. 
Los Altos. Calif., Lange Medical Publications, 1978. 

5. BUMEDINST 6220.13 series, Prophylaxis for Infectious Hepa- 
titis. 

6. Morbidity and mortality weekly report. USDHEW, PHS, CDC, 
Atlanta, Ga. 



Volume 70, April 1979 



11 




The from-life Houdon bust of Jones 



Head of Jones' body photographed 11 April 1905 following 
the autopsy 



John Paul Jones: A Twentieth 
Century Post Mortem 



This year marks the 200th anniversary of one of the 
most famous battles in American naval history. On 23 
Sept 1779, off Flamborough Head, England, the British 
warship, "Serapis. " struck her colors after a vicious 
and bloody moonlight encounter with the ' 'Bon Homme 
Richard. " As the victorious skipper of the outclassed 
and outgunned "Richard," John Paul Jones surely 
achieved his greatest triumph. 

But if his immortal words "I have not yet begun to 
fight," assured Captain Jones a hallowed place in the 
pantheon of American naval heroes, they by no means 
guaranteed his future. The Revolution ended in 1783 
and the Continental Navy ceased to exist. America, the 
Scotsman's adopted homeland, suddenly offered few 
challenges to one who drew vitality and sustenance 
from the sea. 

Jones spent the remaining years of his life in Europe, 
first trying to settle prize claims for his former crew- 
mates and then as advisor and rear admiral in the Navy 
of Catherine the Great of Russia. His health began to 
fail. The cruel Russian winter took its toll and he con- 



tracted pneumonia, a disease that became chronic. 
Even before his Russian sojourn, he displayed evidence 
of bronchiolitis, a condition that may well have ap- 
proached clinical asthma. Malaria had infected him 
years earlier in the West Indies and he was also subject 
to recurring attacks of that disease. 

He returned to Paris in 1790, his voice weakened and 
his diminutive five feet seven inch frame wracked by 
frequent coughing fits. Two years later the once wiry 
seaman had already lost much of his appetite and be- 
gan to show symptoms of jaundice. Jones' limbs 
swelled and 18th century medicine could do little to 
stem his overall physical decline. 

Colonel Samuel Blackden, a North Carolina planter, 
described his last illness: "A few days before his death 
his legs began to swell, which proceeded upward to his 
body, so that for two days before decease he could not 
button his waistcoat and had great difficulty in breath- 
ing. . ." 

On 18 July 1792, Jones succumbed to "dropsy of the 
heart" at age 45. Blackden recalled that "the body was 



12 



U.S. Navy Medicine 



put into a leaden coffin . . . that, in case the United 
States, which he had so essentially served with so much 
honor, should claim his remains they might be more 
easily removed." 

Memories faded and time and neglect gradually 
erased the location of Jones' unmarked grave. Yet 
there were those who had not forgotten. In 1845 Colonel 
John H. Sherburne began a compaign to return the 
hero's remains to the United States. He wrote Secretary 
of the Navy George Bancroft and requested that the 
body be brought home aboard a vessel of the Mediter- 
ranean Squadron. Six years later preliminary arrange- 
ments were made, but those plans fell through when 
several of Jones' Scottish relatives objected. Had they 
not intervened, a far more serious problem might well 
have put a premature end to the whole affair. Where 
was John Paul Jones buried? 

Almost another 50 years passed before another in- 
dividual, the newly confirmed U.S. Ambassador to 
France, Horace Porter, vowed to locate the grave. "I 
felt a deep sense of humiliation as an American citizen 
in realizing that our first and most facinating naval hero 
had been lying for more than a century in an unknown 
and forgotten grave and that no serious attempt had 
ever been made to recover his remains and give them 
appropriate sepulture in the land upon whose history he 
had shed so much lustre." 

After painstaking research into the records, Porter 
narrowed the field to a long abandoned Paris cemetery 
now covered by rows of squalid tenements. 

Exploratory excavations began on 3 Feb 1905. Fifty- 
six days later workmen finally unearthed a lead coffin 
which was opened in the presence of Ambassador 
Porter and other witnesses. Those present were 
amazed to find that the body which had been wrapped 
in linen and packed with straw, had also been im- 
mersed in alcohol. The flesh appeared to be well pre- 
served. Porter wrote: "The face presented quite a 
natural appearance . . . Upon placing [a likeness of 
Jones in profile] near the face, comparing the other 
features and contour of brow, appearance of the hair, 
high cheek-bones, prominently arched eye orbits, and 
other points of resemblance — we instinctively ex- 
claimed, 'Paul Jones'; and all those who were gathered 
about the coffin removed their hats, feeling that they 
were standing in the presence of the illustrious dead — 
the object of the long search." 

Yet the Ambassador realized that he conjectured on 
the skimpiest of evidence. A more scientific analysis of 
the remains was necessary. Immediately a team from 
the Paris School of Medicine began that investigation. 

After removing the linen winding sheet, an anthro- 
pologist carefully measured the cranial features. The 



existence of a "from life" Houdon bust of Jones made 
comparison that much easier. Porter wrote: "Dr. Papil- 
lault, with his delicate instruments, made all the neces- 
sary anthropometric measurements of the head, fea- 
tures, length of body, etc., and found them so entirely 
exact as to be convinced . . . that the length of body, 
five feet seven inches, was the same as the height of the 
Admiral." 

It only remained for the experts to conduct an 
autopsy. The internal organs, flooded with alcohol, 
were as well preserved as laboratory specimens. 
Pleural adhesions were present, particularly over the 
upper lobes. Jones once thought himself infected with 
tuberculosis, yet examination showed no evidence of 
tubercular bacilli. The left lung showed a spot sur- 
rounded by fibrous tissue, a possible remnant of his 
bout with pneumonia. 

The cardiac muscle, still flexible after 113 years, 
showed no signs of pathology. The liver was contracted, 
yellowish-brown in color, and the tissues were dense 
and compact. Several varieties of crystals were inter- 
spersed in the hepatic cells. To the naked eye masses of 
tyrosin in the organ appeared as white opaque gran- 
ules. Otherwise, the liver showed no abnormalities. 
The gall bladder seemed healthy and contained a pale 
yellowish-brown bile of a pasty consistency. The 
stomach was contracted, the spleen somewhat en- 
larged. The tissue of both organs, however, was firm 
and free of lesions. 

The kidneys, very well preserved, were sectioned 




Section of left lung showing focus of chronic broncho-pneu- 
monia (magnified 100 times) 



Volume 70, April 1979 



111 



and observed under the microscope. Clear evidence of 
interstitial nephritis or brightism existed. Dr. Capitan, 
one of the attending examiners, spoke more specifically 
in his report: 

The vessels at several points had their walls thickened 
and invaded by sclerosis. A number of glomerules were com- 
pletely transformed into fibrous tissue and appeared in the 
form of small spheres, strongly colored by the microscopic 
reactions. This verification was of the highest importance. It 
gave the key to the various pathological symptoms presented 
by Paul Jones at the close of his life — emaciation, consump- 
tive condition, and especially so much swelling, which from 
the feet gained completely the nether limbs, then the abdo- 
men, where it even produced ascites (exudat intra abdo- 
minal). All these affections are often observed at the close of 
chronic interstitial nephritis. It can, therefore, be said that we 
possess microscopic proof that Paul Jones died of a chronic 
renal affection, of which he had shown symptoms toward the 
close of his life. 

Capitan's colleague, Dr. Cornil, concluded his report 
of the microscopic examination by saying: "We believe 
that the case in point is interstitial nephritis with 
fibrous degeneracy of the glomerules of Malpighi, 
which agrees with the symptoms observed during life." 
A 1952 analysis of the autopsy report suggested that 
the renal disease may have had its origin both in Jones' 
recurring fevers and a severe respiratory tract infection 
he suffered while traveling to Russia. 

With positive identification, Ambassador Porter re- 
layed his report to Washington and, shortly thereafter, 





Section of kidney showing glomerulose sclerosis and intersti- 
tial nephritis (magnified 100 times) 



Section of left lung showing crystals of ty rosin (magnified 100 
times) 



President Theodore Roosevelt dispatched a naval 
squadron to France to escort the remains home. 

On 6 July 1905, on the 158th anniversary of Jones' 
birth, religious ceremonies were held in Paris. An 
honor guard placed the new oak casket upon a French 
artillery caisson and solemnly the procession moved 
through the Paris streets and down the Champs 
Elysees. Across the Seine, at the Esplanade des 
Invalides, French and American honor guards rendered 
the flag-draped coffin the highest military honors. The 
magnitude of the occasion only served to contrast the 
hasty and very private funeral that preceded the ad- 
miral's burial 113 years before. 

The journey was not yet over. After the transatlantic 
crossing and the speeches, the body was carried to the 
Naval Academy's Bancroft Hall and placed behind a 
staircase upon two sawhorses. There it rested for seven 
years. On 26 Jan 1913 the remains of John Paul Jones, 
rescued from the obscurity of a forgotten grave, were 
finally laid to rest in a crypt at the Academy chapel. 

References 

1. Dale PM: Medical Biographies: The Ailments of Thirty-Three 
Famous Persons. Norman, Okla., 1952. 

2. John Paul Jones Commemoration at Annapolis. House docu- 
ment No. 804, 59 Congress, First Session. 

3. Hollingsworth PP: "Review of the Autopsy Reports on the 
Body of Admiral John Paul Jones." Medical World 53:305, 1935. 

4. Vincent E: "Death Comes for the Admiral." Surgery, Gynecol- 
ogy and Obstetrics 89:778-783, 1949. 



14 



U.S. Navy Medicine 



Use of Facsimile Transmitters for a 
Clinical Pharmacy Program 



LCDR Phillip T. Riley, MSC, USN 
LT Dominick DePolo, Jr., MSC, USN 
LTJG Charles L. Hall, Jr., MSC, USNR 



The accurate and timely flow of 
information from client to supplier 
is one of the most critical issues in 
the operation of a high-volume 
diversified pharmacy. It is essential 
that ward orders, intravenous ad- 
mixture (I.V.A.) orders, and unit 
dose drug (U.D.D.) requests are re- 
ceived promptly and accurately for 
prompt pharmacy response for pa- 
tient care. Historically, this infor- 
mation transmittal has been carried 
out either by phone conversation or 
by hand-carried request forms. Not 
only is this traditional process time 
and labor consuming, but also lends 
itself to communication and trans- 
cription errors. The conveyance of 
information relative to patient care 
is essential for the initiation and 
management of clinical pharmacy 
services in a hospital with a limited 
staff of pharmacists and pharmacy 
technicians. Requests from the 
pharmacy and constantly changing 
orders that utilize the Unit Dose 
Drug Distribution System both must 
be accurate and prompt. The same 
holds true for orders for intravenous 
admixtures prepared by the Phar- 
macy Service. Centralized phar- 
macy services cannot respond ra- 
pidly to ward orders or direct pa- 
tient medication orders without 
some alternative to "leg power" for 
information transmission. 

At the Naval Aerospace and Re- 



From the Pharmacy Service, Naval Aero- 
space and Regional Medical Center, Pensa- 
cola. Fla. 32512. 



gional Medical Center, Pensacola, 
Florida (NARMC), we feel we have 
found the answer to the "leg 
power" problem. In a facility with- 
out a pneumatic tube system for 
transmittal, an attractive alternative 
is facsimile transmitters strategical- 
ly placed throughout the hospital 
and easily accessible to Nursing 
Service personnel. NARMC is a 
medium-sized facility with an au- 
thorization of 126 beds, but a maxi- 
mum capacity of 350 beds. Wards 
and clinics are spread over eight 
floors and two wings, East and 
West. The receivers are placed in 
the Pharmacy near the areas of in- 
patient care drug dispensing. The 
Pharmacy Service is divided into 
two major dispensing areas — Out- 
patient Services and Inpatient Ser- 
vices. Both are physically separated 
within the pharmacy spaces to avoid 
confusion and conflict in procedures 
required by the two vastly different 
services. 

Prior to the installation of facsim- 
ile transmitters, Nursing Service 
personnel delivered ward orders to 
the pharmacy by 0900 daily. Phar- 
macy Service gathered intravenous 
admixture orders by means of ward 
rounds made twice in the morning 
and once in the afternoon. Time 
consumption resulted in a signifi- 
cant loss of man-hours. Prior to the 
installation of the facsimile trans- 
mitters, I.V.A. rounds took between 
68 and 90 man-hours per month to 
cover the nine wards, clinics, and 
the Emergency Room serviced by 



the I.V. admixture program. Since 
the rounds could be made only by 
personnel qualified to prepare I.V. 
additive orders, a significant time 
lag existed between ordering and 
delivery of completed I.V.A.'s. Ser- 
vice was limited due to personnel 
requirements. 

All inpatient drug orders of 
I.V.A.'s or unit dose drugs must be 
taken from a direct copy of or the 
original physician orders. In keep- 
ing with this concept, the pharma- 
cist should receive drug orders from 
the physician without an intermedi- 
ate transcribing step. A method of 
receiving a copy of the physician's 
original orders, therefore, had to be 
devised. 

A revision of standard forms 
{Doctors Orders) was required to 
facilitate ease of transmitting and 
receiving a copy of the physician's 
orders. The Standard Form 508 was- 
made available in a five-part NCR 
format. This five-part SF508 would 
provide more than an adequate 
number of copies for physician's 
orders. With this document, a direct 
copy of physician's orders becomes 
a reality. The use of the new Doctors 
Order form alone would decrease 
nursing service time for transcrib- 
ing of orders and Pharmacy Service 
time for copying orders on the ward 
to an I.V.A. order card. The SF508 
five-part lends itself perfectly to the 
installation of the facsimile trans- 
mitters. 

Facsimile transmitters are simply 
photo-scanning devices that trans- 



Volume 70, April 1979 



15 



mit copies via a pair of converted 
phone lines or pulled pairs to a re- 
ceiver. This equipment can copy 
and transmit an 8V2 X 11 sheet of 
paper in 1.2 to 1.4 minutes. Utiliz- 
ing the facsimile transmitters, 
orders can be written, transmitted, 
and delivered promptly without 
time consuming ward rounds and 
the danger of transcription error. 
These copies are interpreted by the 
pharmacist, filled, and delivered 
within 10 minutes. After receiving 
transmissions from the ward, the 
orders are time-dated, separated, 
and given to the appropriate section 
of the inpatient service. Non-unit 
dose ward orders for ward stocks 
are passed to the technician filling 
ward issues. Unit dose wards utilize 
a combined unit dose-I.V. admix- 
ture integrated program. Those 
orders for wards not yet integrated 
to the unit dose-I.V. program are 
interpreted, filled, and catalogued 
by ward for future reference. Copies 
of the original orders and change 
orders are retained for reference 
until the I.V. admixtures are dis- 
continued. 

With the time saved by use of the 
facsimile transmitter, it was possi- 
ble to reschedule pharmacists and 
technicians to provide 7-day-a- 
week, 18-hour-per-day coverage for 
l.V. admixture services. Further re- 
scheduling and technician training 
when completed will allow 7-day-a- 
week, 24-hour-per-day coverage, in 
effect, a total I.V. admixture pro- 
gram. Additionally, improved in- 
formation transmission and the time 
saved by not having to make ward 
rounds for pickup of unit dose drug 
orders has permitted unit dose drug 
response to wards in less than 10 
minutes. This capability has re- 
sulted in the maintenance of virtual- 
ly no ward drug stocks except for 
routine ward stock solution supplies 
and a minimal supply of emergency 
parenteral drugs. 

The facsimile transmitter system 




Facsimile receivers located in one of the pharmacy clinical service areas 



installed at NARMC is divided into 
two commuted units, one for all 
West wing wards and one for those 
wards in the East wing. A unit con- 
sists of five transmitters committed 
to one receiver in the pharmacy. By 
splitting the ten transmitters into 
two units, we have decreased the 
in-use time of each receiver so that 
availability time of each receiver is 
increased. Each transmitter is 
equipped with an automatic docu- 
ment loader that allows up to 50 
forms to be presented for transmis- 
sion at one time. The loader will 
take intermixed sizes and weights of 
paper. Unattended operation is 
facilitated by a polling system in the 
receiver which scans each transmit- 
ter and authorizes it to send. Addi- 
tionally, a lockout system acts as a 
sentry by preventing a transmitter 
on the line from sending to a re- 
ceiver already in use. The locked- 
out transmitter holds the material 
and when the receiver becomes 
available, transmits it automatical- 
ly. A systems assurance furnishes 
electronic monitoring of both the 
circuit and the receiver status 
during transmission. Should an 



open line occur or the receiver be- 
comes inoperable, the transmitter 
terminates operation. With these 
features, it is easy for information to 
be transmitted quickly and efficient- 
ly. Operator involvement with the 
transmitter is limited to loading the 
documents to be transmitted. 

The receivers located in the phar- 
macy are placed so as to assure 
frequent monitoring. Each of the 
two receivers is equipped with an 
automatic document cutter and 
stacker that cuts each transmitted 
document to the size of the original 
document. Since maximum time of 
transmission for an 8Vj X 11 docu- 
ment is 1.4 minutes, there have 
been no problems in waiting time 
for transmission of orders. Each re- 
ceiver processes a daily average of 
125 documents at the Naval Hos- 
pital. 

The cost of the system relative to 
manpower savings authorized over 
the life expectancy of the equipment 
and adjusted for state-of-the-art 
changes can easily be justified. 
Over a four- year period, the cost of 
a technician or pharmacist required 
to act as a runner would far exceed 



16 



U.S. Navy Medicine 



the purchase cost of the system. 
The initial investment for ten trans- 
mitters, two receivers, listed op- 
tional equipment, and a six-month 
supply of printing blades and paper 
totaled $20,263.00, including instal- 
lation costs. Rental of the equip- 
ment is possible, but would exceed 
purchase costs over a two-year 
period. Yearly maintenance con- 
tracts are available from the manu- 
facturer, but it is more economical 
to utilize medical repair personnel 
on regular PM schedules. These 
personnel can be trained by the 
manufacturer at minimal cost. Pa- 
per supplies for the receiver for 
printout facsimile come in a 400-foot 
roll and give approximately 350 
8V2 X 11 documents. The cost per 
document transmitted is approxi- 
mately 3.4 cents. This cost includes 
replacement printer blades. NAR- 
MC chose the Infolink Scanatron 
System for installation based on 
careful comparison of cost, mainte- 
nance, reliability, and system re- 
quirements. 

Funding for the installation of the 
facsimile transmitter system was 
requested from BUMED as an in- 
cluded equipment system require- 
ment for the proposed I.V. Admix- 
ture-Unit Dose proposal funding 
request in October 1977. The ap- 
proval for funding and equipment 
was received in January 1978, and 
equipment was purchased in March 
1978. Once justification of need for 
the transmission system was made, 
there was little problem in receiving 
the funding requested. 

Installation of the equipment was 
a joint effort of the manufacturer, 
phone company, and staff mainte- 
nance personnel. Installation was 
completed in early August 1978. Im- 
mediate utilization of the system 
began after installation with a 
minimal amount of inservice train- 
ing required for Nursing Service 
personnel. Each transmitter is 
equipped with a manufacturer-sup- 



plied instruction manual and a 
simplified memo from the phar- 
macy. Transmitters are strategically 
located on each ward nursing sta- 
tion, assuring easy access to users, 
yet placed out of the way of ward 
business whenever possible. Ini- 
tially, use was limited to daily ward 
orders and I.V. admixture orders. 
With the initiation of the Unit Dose 
Drug Distribution System in Sep- 
tember 1978, utilization of the 
system increased significantly. Use 
of SF508 five-part doctors orders 
forms, as previously mentioned, 
facilitate use of the equipment. The 
orders need not be removed from 
the chart to allow copying. As an 
order is written by the physician, 
one of the carbonless copies is taken 
from the chart and transmitted. 
When deliveries are made by the 
pharmacy, the copies are picked up 
and compared to the transmitted 
copies simply as a second check for 
accurate interpretation. It would be 
virtually impossible to introduce a 
total unit dose I.V. program into a 
hospital of this size without using 
this type of transmission system. It 
would be impossible to transmit the 
volume of information required for 
24-hour coverage of inpatient medi- 
cation orders. With this system on 
line, we have been able to monitor 
drug therapy and provide a greater 
level of patient care and safety. 
Omission or mistranscription of 
doctors orders to Medication Ad- 
ministration Records (MAR) and 
medication cards if used, can easily 
be detected because, with the new 
system, two parties interpret orders 
and compare transcription prior to 
drug administration. 

The transmitters provide legible 
facsimile copies without sacrificing 
resolution. A comparison of the 
original SF508 five-part copy and its 
transmitted facsimile copy show 
little difference in legibility for 
transcription. The equipment in- 
stalled in NARMC has two modes of 



transmission. Document mode pro- 
vides high speed rates for alpha 
numeric information. Each trans- 
mitter can be calibrated for type of 
paper, and color of copy to be trans- 
mitted. The photo mode furnishes a 
slower transmission rate for photo 
reproduction and half tone resolu- 
tion. If a facsimile copy is received 
that is not perfectly clear, a phone 
confirmation or receipt of the origi- 
nal order copy can be compared be- 
fore administration of the drug 
order or l.V.A. to the patient. 

Future plans for utilization of the 
equipment provide a wide range of 
possibilities. Since the transmitters 
are already located on the wards, it 
is possible to provide switching 
wires on line to transmit to a variety 
of receivers. Diet schedules could 
be transmitted from wards directly 
to the dietitian. This again would 
eliminate the need for diet rounds. 
The transmission of copies of physi- 
cian orders lends itself to the accu- 
rate and timely identification of pa- 
tients for drug utilization audits. 
Pharmacy Inpatient Service can 
readily identify patient charts for 
audit and provide complete infor- 
mation for review. This procedure is 
currently being tested in conjunc- 
tion with the Unit Dose Drug Distri- 
bution-Intravenous Admixture Pro- 
gram. Lab requests could be trans- 
mitted from the wards to the 
laboratory. By placing additional 
receivers on each ward and by utili- 
zation of devices, lab results could 
be transmitted back to the wards. It 
is obvious that a wide variety of 
possibilities for use of facsimile 
transmitters exists in Naval hospi- 
tals. 

Any questions or comments re- 
garding the utilization of facsimile 
transmitters may be directed to 
Chief, Pharmacy Service, Naval 
Aerospace and Regional Medical 
Center, Pensacola, Fla. 32512. FTS 
904-948-6721, or Autovon 922-6721, 
Commercial 904-452-6721. 



Volume 70, April 1979 



17 



The Origins of BUMED Audiovisual Training 



Kenneth W. Hammel 



By 1941 the coming of war ap- 
peared to be a certainty, and for 
over a year a serious mobilization 
effort had been under way. There 
was no question that American in- 
dustry could rapidly retool to prod- 
uce the equipment for war. But 
could training, unprecedented in 
scale and complexity, be accom- 
plished with equal speed and effec- 
tiveness? This was a major concern 
at the highest planning levels. 

For a quarter of a century motion 
pictures, an American innovation, 
had provided mass entertainment. 
Why, then, could not this medium 
— and the skills of the film industry 
— be transformed into a tool for 
mass training? 

Recognizing this potential, Secre- 
tary of the Navy Frank Knox, on 31 
Oct 1941, signed a circular letter 
that officially provided for audio- 
visual training in the Navy and 
delegated responsibility for its de- 
velopment to three Navy offices: 
The Bureau of Navigation {to be re- 
named the Bureau of Naval Person- 
nel in May 1942), the Bureau of 
Aeronautics (known today as the 
Naval Air Systems Command), and 
the Bureau of Medicine and Sur- 
gery. BUNAV was given responsi- 
bility for all genera] training, 
BU AER for film production and con- 
tract management, and BUMED for 
all medical and dental training. 



From the Audiovisual Production Division, 
Nava! Health Sciences Education and Train- 
ing Command, Bethesda, Md. 20014. 



On 27 Nov 1941, RADM Ross T. 
Mclntire, the Surgeon General as 
well as personal physician to Presi- 
dent Roosevelt, directed the officer 
in charge of the Bureau's Preven- 
tive Medicine Division to call a 
meeting of a Visual Education 
Board "at the earliest practical date 
for the purpose of considering 
visual aids to education." This 
board met the following week and, 
while the minutes of the meeting 
have not survived, a summary of the 
proceedings is of interest. 

The board first assessed existing 
resources: 

Question: How many training films 
are in the BUMED inventory? 
Answer: Six, counting two films 
that are not bona fide training aids. 

Question: What can be requisi- 
tioned from the Army and other 
sources? 

Answer: Very little from the Army. 
A few films can be obtained from 
commercial sources but not dealing 
with military medicine. 

The board, having established 
that software was virtually non- 
existent, proceeded to select the 
most suitable audiovisual equip- 
ment. The 16-mm sound motion 
picture format, having become the 
standard everywhere, was adopted. 
The amazing new color film, Koda- 
chrome, had become available, but 
it was expensive and technically 
difficult to use. So, it was agreed, 
black-and-white would be the stan- 



dard film material, and Koda- 
chrome would be used only where 
color was essential to instruction. In 
addition, film strips using 78-rpm 
records for sound were also 
adopted. 

Next, the board considered the 
audiences for audiovisual instruc- 
tion. Two broad audiences were 
identified, "All hands" was the 
audience assigned the highest 
priority because of a pressing need 
for training in personal health care 
and first aid. Hardly less urgent 
were the needs of the medical/den- 
tal professional, whose training re- 
quirements ranged from Hospital 
Corps basics to highly specialized 
surgical procedures. 

By the end of the meeting, pro- 
duction had been authorized for six 
color motion-picture training films 
on "personnel damage control" and 
a series of film strips on first aid 
techniques. The plans for these 
films were to be presented at a 
meeting scheduled for mid-Decem- 
ber. 

Meanwhile, Secretary of State 
Cordell Hull was conferring with 
Japanese Ambassador Nomura and 
Special Envoy Kuruso, a meeting 
that ended abruptly with news of 
the Pearl Harbor attack. The inevi- 
table had come with tragic sudden- 
ness. 

At the next meeting of the Visual 
Education Board on 15 Dec 1941, 
the participants, undoubtedly famil- 
iar with the grim casualty figures at 
Pearl Harbor, expedited the de- 
velopment of the training aids on 



is 



U.S. Navy Medicine 



personnel damage control and first 
aid. Persistence and courage were 
probably the most valuable qualities 
they could have brought to the 
meeting, because the training prob- 
lem must have looked overwhelm- 
ing, even futile, in the face of the 
world situation. Japan was rampag- 
ing through the Pacific on a tide of 
victories, and Germany, secure on 
its western flank, had panzer divi- 
sions at the gates of Moscow. 

Whatever the future, the board 
knew what every practitioner of 
military medicine in every war has 
known — that it is not enough to 
treat battle wounds; you must also 
prevent and treat diseases, not the 
least of these being VD. Appropri- 
ately, the production of a sex educa- 
tion program was authorized. What 
was different about this war was 
that film, rather than the chaplain, 
was being used for the first time to 
teach VD prevention — and two films 
were needed, one for men and one 
for women, since the WAVE organi- 
zation was now a reality. 

The plan for these films was the 
work of LTJG George W. Mast, 
MC, USN, of the Bureau's Preven- 
tive Medicine Division and a mem- 
ber of the Visual Education Board. 
Dr. Mast had searched far and wide 
without success for films on sex 
hygiene. Sex and VD were still 
topics kept in the closet. The films 
he produced were among the first 
sex education films that dealt with 
the subject frankly and openly in 
word and image. 

Dr. Mast was a key figure in BU- 
MED audiovisual training. Con- 
vinced that the motion picture was 
the most effective means of popular 
education, he was the first head of 
the Bureau's Audiovisual Education 
Section and the first technical 
adviser on a medical training film. 

Another important figure in the 
early development of BUMED 
audiovisual training activity was 
CDR (later CAPT) Joseph S. Barr, 



MC, USNR, an orthopedic surgeon 
from Boston, who had recently re- 
ported to active duty in the Bureau 
and was eventually to relieve Dr. 
Mast as head of the Audiovisual 
Education Section. In April 1942 
Barr wrote that "a carefully planned 
and rapidly expedited program of 
medical film production should be 
undertaken by the Bureau of Medi- 
cine and Surgery. This should result 




CAPT Joseph S. Barr, MC, USNR 

in lowered mortality and less crip- 
pling among ever-increasing casual- 
ty lists." BUMED's advisory board 
endorsed his recommendations and 
advocated a program of obtaining 
audiovisual training aids from exist- 
ing government or commercial 
sources where possible and satisfy- 
ing additional needs by contract or 
by in-house resources. 

The direction, purpose, and goals 
of audiovisual education had been 
established. They could not be ac- 
complished, however, without the 
mobilization of specialized motion 
picture talent from the industry — 
cameramen, editors, actors, direc- 



tors, writers, etc. All the services 
were competing for this talent and 
the Navy succeeded in building an 
impressive cadre. It included "box 
office" names such as Gene Kelly, 
Eddie Albert, Richard Carlson, 
John Ford, and hundreds of lesser- 
known but highly skilled profes- 
sionals from major studios and com- 
mercial filmmaking companies. 

Pharmacist's Mate Second Class 
Paul Coulter, who as a civilian had 
been an animator at the Disney 
studios, reported to the Naval 
Medical School, Bethesda, in April 
1942. The school was occupying the 
basement of the newly constructed, 
still uncommissioned National 
Naval Medical Center. Coulter, 
designated a medical illustrator, 
teamed up with Pharmacist's Mate 
Second Class Earl Pierce, who had 
been a civilian film writer, to prod- 
uce the first BUMED in-house film 
project, "Life Cycle of Endamoeba 
Histolytica." Pierce wrote the 
script, and Coulter prepared the art, 
borrowed a 16-mm camera, and im- 
provised an animation stand to 
shoot the film. Dr. Barr was so im- 
pressed with the results that he was 
instrumental in establishing the 
Medical School as a center for in- 
house audiovisual production. 

The most elaborate and complex 
training film project produced by 
BUMED during the war was the 
"Combat Fatigue" series. These 
films probed and analyzed the fears 
and tensions experienced by men in 
battle, and were intended for use by 
both therapists and psychiatric pa- 
tients. The project has a pioneering 
effort in using the film as a thera- 
peutic tool. To give credibility and 
realism, the "Combat Fatigue" 
productions required production 
values on a Hollywood scale. Fortu- 
nately, the Navy Photo Science 
Laboratory (now the Naval Photo- 
graphic Center) had been com- 
pleted at Anacostia. It contained a 
large sound stage and the latest 



Volume 70, April 1979 



19 




Film taught everything from basic nursing care to sophisticated surgical procedures during World War II. Here a corpsman 
demonstrates hospital bed-making 



motion picture equipment. Its staff 
included numerous Hollywood pro- 
fessionals, from set builders to 
actors. LTJG Gene Kelly was se- 
lected for the lead role of a sailor 
who had experienced an emotional 
breakdown from combat stress. 

CDR Howard P. Rome, MC, 
USN, the technical adviser for the 
series, described its purpose as 
being "... to acquaint the patient- 
audience with the background and 
the mechanics of their psychological 
disabilities, so that they see them- 
selves as others see them . . . and to 
help them to understand more fully 



why they are disabled by explaining 
the purpose and meaning of the 
symptoms ... A straightforward 
factual account, however interest- 
ingly portrayed, does not constitute 
psychiatric treatment . . . The basic 
task of a psychiatric film designed 
for the treatment of patients is to 
coordinate simple, understandable 
educational training techniques 
rooted in facts with an interpretive 
approach which compels each mem- 
ber of the audience to identify him- 
self with the characters and situa- 
tions shown." 

Unlike this series, most BUMED 



training films did not require dra- 
matic treatment, elaborate sets, and 
Hollywood talent, but, instead, 
good expository development of 
word and picture. The typical BU- 
MED audiovisual training aid is 
often called a "nuts and bolts film," 
characterized by a short introduc- 
tory statement of purpose, a logical 
development of teaching points, 
and a summary. Generally, the 
commentary or narration is "off 
screen," and the words support the 
picture rather than the reverse. For- 
tunately, most medical and dental 
subjects are amenable to this type 



20 



U.S. Navy Medicine 



of treatment. BUMED recognized in 
1942 what Marshall McLuhan ob- 
served in recent years: that, of all 
professions, medicine and dentistry 
are the most suitable for audiovisual 
instruction. 

The success of the "nuts and 
bolts" concept is exemplified in the 
film series, started in 1942, entitled 
"Care of Sick and Injured by Hospi- 
tal Corpsmen." Traditionally, 
corpsman training consisted of a 
series of didactic lectures followed 
by on-the-job training in the ward. 
The film series was conceived as a 
means of assisting and speeding up 
the "elbow teaching" process. The 
technical adviser, LTJG Jean Byers, 
NC, USNR, experienced in profes- 
sional nursing and a former teacher 
at the University of Washington, 
skillfully developed a series of 14 
films that, in today's terminology, 
would be called single-concept, cur- 
riculum-oriented audiovisual in- 
struction. An introductory film pro- 
vided a general orientation to the 
corpsman's duties and responsibili- 
ties. The other films, while reiterat- 
ing general themes, taught specifics 
such as preoperative care, blood- 
pressure reading, bed baths, and 
appliances. 

As 1942 closed, the Bureau had 
produced at least two dozen films 
and film strips, with many more in 
production. In December BUMED 
received a letter from BUPERS, re- 
porting on the findings of a Navy 
Audiovisual Aids Board, which in- 
cluded this statement: "In general, 
wherever they have been used in 
the naval establishment during the 
past year, motion pictures and film 
strips have been conspicuously ef- 
fective in expediting the training of 
officers and men .... At present 
only one-third as much use is being 
made of motion pictures and film 
strips as can be made." 

In the remaining war years, BU- 
MED would meet the goal of accel- 
erated audiovisual education. While 



no complete record exists of its 
audiovisual production during the 
war years, it is probable that well 
over 100 motion pictures and film 
strips were produced for diverse 
and varied training needs. The titles 
of a few of these films illustrate this 
variety: "Preparation of Liquid 
Plasma," "Fractured Femur — 
Open Reduction," "The Two-Step 
Test for Myocardial Function," and 
"Surgical Consideration for Hyper- 



pituitarism." From the inception of 
the audiovisual program, the Dental 
Corps was an enthusiastic support- 
er, and five films were completed 
under Naval Dental School auspices 
by mid-1942. "Treatment of Jaw 
Fractures," "Oral Surgery — Api- 
coectomy — Two Methods," and 
"Duties of Dental Technicians" are 
examples. 

RADM Mclntire in June 1943 
proposed a program to document 




LTJG Gene Kelly, USN, in the role of a combat fatigue casualty in a BUMED train- 
ing film for psychiatric patients 



Volume 70, April 1979 



■21 



photographically the medical and 
surgical management of naval com- 
bat casualties, showing casualties 
on the battlefield, initial treatment, 
evacuation, treatment en route, and 
final treatment and management at 
base hospitals. In addition, disease 
control and disease treatment prob- 
lems and procedures in various 
theaters of operation were to be 
documented. As a result of this 
proposal, Naval Field Medical 
Photographic Units were promptly 
organized and deployed. Unit Num- 
bers 1, headed by LTJG Harry 
Tebrock, MC, USNR, covered activ- 
ities at Guadalcanal, Bougainville, 
and the New Hebrides in its first 
tour and on a second tour partici- 
pated in the Saipan invasion. 

Unit Number 2, under LCDR 
Clement C. Lay, MC, USNR, oper- 
ated with the Eighth Fleet during 
the North African invasion and then 
went into Italy with the Fifth Army. 
Unit Number 3, led by LT Frederick 
J. Faux, MC, USNR, landed with 
the Marines on Iwo Jima. 

Two other units were assigned 
special missions. One, directed by 
ENS Bernard Dryer, USNR, in July 
1944, entered Dakar to document a 
devastating bubonic plague epi- 
demic in French West Africa. The 
second unit, under LCDR Samuel F. 
Harby, USNR, filmed plastic and 
reconstructive surgical manage- 
ment procedures at Navy and Army 
medical facilities throughout the 
world. 

Footage shot by these units was 
rushed back to the U.S. for process- 
ing. At the Bureau, film was edited 
into 10- or 20-minute "March of 
Time" style programs issued on a 
monthly basis. They were invalua- 
ble in keeping headquarters abreast 
of military medical activities — prob- 
lems and progress — throughout the 
world and enabled professionals to 
keep up to date on military medicine 
innovations. The films became 
known as the "Medicine in Action" 




In a scene from "Combat Fatigue," a sailor, portrayed by Gene Kelly, talks about 
his problems with the psychiatrist 



series, and the titles are a veritable 
catalog of the paramount concerns 
of the Navy Medical Department 
during World War II: "Pacific 
Enemy No. 2 — Malaria," "Head 
Injury — Report of a Battle Casual- 
ty," "Typhus in Naples," "Evacua- 
tion of Casualties — Saipan," and 
"Multiple Wounds." 

The final months of the war saw a 
marked change of emphasis in 
audiovisual subject matter. The end 
of hostilities was in sight and the 
problems of demobilization became 
a matter of concern. For the Navy 
Medical Department, recovery and 
rehabilitation of casualties assumed 
the highest priority. Thus, films for 
all hands were produced, with such 
titles as "Voyage to Recovery" and 
' ' So Many Han ds . " For the medical 
team, such films as "Prosthesis — 
Ocular Replacement" and "Ampu- 
tations: Guillotine of the Lower Ex- 
tremity" were made. 

Within months after the Japanese 
surrender in August 1945, demobili- 
zation had its own impact on the 



BUMED Audiovisual Education 
Section. It was reduced by attrition 
to zero staffing. This situation pre- 
vailed for several months until 
CAPT Robert V. Schultz, MC, USN, 
was assigned the task of rebuilding 
the audiovisual training unit. 

Dr. Barr returned to his orthope- 
dic practice in Boston in late 1945. 
Later he was to write of his Navy 
filmmaking experiences: "As one 
who has been through this rather 
debilitating process a fair number of 
times recently, I would say this — 
with the hope of saving someone 
from a heart-rending experience: 
Beware of taking a camera and try- 
ing to film an instructional picture 
without first writing a script and re- 
viewing the practical elements of 
the problem. Delay, frustration, 
failure and unwarranted prejudice 
against films as teaching aids are 
more than likely to result from 
shooting 'off the cuff."' 

This was good advice for medical 
film producers and technical ad- 
visers in 1945. It remains so in 1979! 



U.S. Navy Medicine 



Professional 



Emotional Problems After 
Therapeutic Abortion 



CDR Jesse 0. Cavenar, Jr., MC, USNR-R 
Gregory J. O'Shanick, M.D. 
Ronald J. Taska. M.D. 



Recently the issue of therapeutic abortion has be- 
come an area of controversy and concern in the military 
services as a result of Congress prohibiting the use of 
federal funds for abortion except when the life of the 
mother would be endangered, when the pregnancy has 
resulted from rape or incest, or when the mother might 
suffer marked physical impairment. 

Until the ban was imposed, military medical depart- 
ments were performing a sizeable number of therapeu- 
tic abortions. For example, since 1974, military person- 
nel and dependents have received about 26,000 
abortions per year; approximately 60% have been 
under the CHAMPUS program with the remaining 40% 
performed in military hospitals (1). In this country, over 
1.1 million therapeutic abortions were performed last 
year. Clearly, therapeutic abortion is a widespread pro- 
cedure in both military and civilian populations. 

The scientific literature which began to appear after 
therapeutic abortion became a common procedure indi- 



Dr. Cavenar is chief of the Psychiatry Service at the Veterans 
Administration Hospital, and associate professor of psychiatry at 
Duke University School of Medicine, Durham, N.C. 27705. 

Dr. O'Shanick is a resident in psychiatry at the Veterans Adminis- 
tration Hospital, and Duke University School of Medicine, Durham, 
N.C. 

Dr. Taska is a staff psychiatrist at the Veterans Administration 
Hospital, and assistant professor of psychiatry at Duke University 
School of Medicine, Durham, N.C. 



cated that there were few, if any, emotional sequelae. 
Part and associates (2) reported that therapeutic abor- 
tion has minimal or no emotional impact on women 
without a psychiatric history. Ewing and Rouse (3) con- 
cluded that women without current psychiatric illness 
withstood the procedure without difficulty. Osofsky and 
Osofsky (4) did follow-up studies on 250 healthy women 
who had received abortions and reported few psycho- 
logical difficulties. Werman and Raft (5) studied over 
120 women up to 14 months after abortion; they con- 
cluded that in only one patient could an emotional dis- 
turbance be directly attributed to the abortion. Many 
other reports arrived at basically the same conclusions. 
Only within the past two years have reports appeared 
suggesting that there are emotional sequelae, at times, 
to therapeutic abortion. Spaulding and Cavenar (6) re- 
ported on two patients who became psychotic following 
the procedure. Cavenar et al (7) described five patients 
who experienced varying degrees of psychological dif- 
ficulty; one patient experienced an agitated depression, 
another a schizophrenic decompensation, and the third 
a paranoid reaction. The other two patients experienced 
difficulty after other members of the family had the 
procedure. Another report by Cavenar et al {8) de- 
scribed two patients who experienced recurring ab- 
dominal pain and depression on an anniversary reaction 
basis following therapeutic abortion. Anniversary re- 
actions have been described in a previous communica- 
tion in this journal (9); essentially, one relives the emo- 



Volume 70, April 1979 



23 



tional aspects of a particular trauma at anniversaries of 
the trauma without being consciously aware of the con- 
flict. 

The purpose of this paper is to report on further cases 
of emotional difficulty we have seen following thera- 
peutic abortion. Our experience is illustrated by the 
following reports: 

Patient 1. Ms. A, a 34-year-old married woman, was 
seen in psychiatric consultation after her third admis- 
sion to the dermatology service. She had previously 
been hospitalized for alopecia which had been subse- 
quently determined to be factitious; outpatient psycho- 
therapy had been suggested at that time for trichotillo- 
mania but she was resistant to the notion. 

The present admission was for a condition which was 
felt to be Behcet's syndrome, characterized by lesions 
of the mouth, genitals, and skin. The trichotillomania 
persisted as on previous admissions; psychiatric con- 
sultation was requested specifically because she was a 
poor compiler with her treatment regimen. 

During the initial psychiatric interview she volun- 
teered that, at age 18, she had become pregnant after 
forced intercourse with her boyfriend. She had secured 
an abortion during the fifth month, and shortly after- 
ward had experienced a depressive disorder requiring 
psychiatric hospitalization. Within one year she had 
met her current husband, and had married. 

Soon after the marriage she began to experience ex- 
cruciating headaches; the only relief she could find was 
to pull the hair from what she perceived as a "boil on 
the scalp." In her mind, this allowed purulent material 
to drain from her head, and thus relieve the headache. 
Her husband had also become involved in removing her 
hair. Significantly, she had always prided herself on her 
appearance and beauty, particularly her beautiful hair. 

She was able to verbalize the fact that she considered 
the alopecia and Behcet's lesions as punishment and 
atonement for having had an abortion. Brief psycho- 
therapy was begun while she was hospitalized; 
attempts were made to have her relive emotionally the 
period around the abortion and to explore the genesis of 
the overwhelming guilt. She displayed persistent 
resistance to exploring the feelings and became in- 
creasingly oppositional, but the psychotherapy did 
decrease her self-destructive behavior during the hos- 
pitalization. 

There was a strong suspicion by both his attending 
physician and the consultants who examined her that 
the lesions of the mouth, genitals, and skin were also 
factitious and self-induced. This was never proved, and 
the patient denied any questions raised concerning that 
etiology. At the time of discharge from the hospital, it 



was suggested that she continue in outpatient psycho- 
therapy. She declined, and therefore no follow-up is 
available. 

Dynamically, the patient felt extreme guilt about 
having had an abortion. We were never able to under- 
stand enough about her early life experiences to know 
why the guilt was so great; this lack of understanding 
was primarily due to her oppositional attitude. It was 
clear, however, that her symptoms of trichotillomania 
and probable self-induced skin lesions were extreme 
masochistic responses to the guilt which she had ex- 
perienced. This response to guilt had become so fixed 
and engrained that it was now an aspect of her basic 
personality structure. 

Patient 2. Ms. B, a 25-year-old professional woman, 
sought psychiatric treatment for recurrent episodic de- 
pression which was now in remission. This depression 
had been characterized by vegetative signs of sleep 
disturbance, weight loss, and crying spells, suggesting 
a moderately severe disorder. 

At the time of initial evaluation, the mental status 
examination revealed a woman who was coherent, 
logical, and relevant with no evidence of psychosis and 
she was not currently depressed. She revealed that she 
had undergone a therapeutic abortion 14 months 
earlier; in describing her depressive episodes, it be- 
came apparent to the examiner that one severe depres- 
sion had occurred at what would have been the 
expected date of delivery of the fetus, and that another 
depression had occurred at the first anniversary of the 
therapeutic abortion. 

Outpatient psychotherapy was begun with the goal of 
resolving her feelings, and the obvious emotional con- 
flict, concerning the abortion. Progress was slow, but 
clinically apparent, until the one year anniversary of the 
expected date of delivery. At that time, the patient 
became psychotic; persecutory delusions and marked 
depression necessitated psychiatric hospitalization on a 
closed ward. She reconstituted over a two-week period 
with supportive psychotherapy and a drug combination 
of norpramine (Aventyl) and perphenazine (Trilafon). 
She was transferred to an open ward, and a more inten- 
sive psychotherapeutic endeavor was begun; after an 
additional three months hospitalization, she was dis- 
charged, capable of returning to her professional work. 
Maintenance medication consisted only of a nightly 
dose of norpramine. She continued in psychotherapy on 
an outpatient basis; interestingly, she experienced a 
mild exacerbation of depression at the two year anni- 
versary of the abortion. This depressive episode was 
mild compared to the previous episodes, due primarily 
to the effectiveness of the psychotherapy. 



24 



U.S. Navy Medicine 



Dynamically, this patient had suffered several 
significant losses in her childhood. While the mother 
was pregnant with the patient, the father had deserted 
the family; an aunt and uncle had cared for the patient 
after her birth. When she was three years old, her uncle 
had died suddenly; in response to his death, the patient 
developed a severe speech impediment which required 
two years of speech therapy to resolve. 

These early life losses which the patient had experi- 
enced contributed to the marked feeling of loss and 
guilt which she experienced after her abortion. 

Patient 3. Ms. C, a 24-year-old single female, pre- 
sented at 4 a.m. as a psychiatric emergency because 
she could not sleep following a conflict with her boy- 
friend. 

The mental status examination revealed a lady who 
was not psychotic or depressed and denied any 
symptoms of either. Interestingly, she did admit that 
for the past six months she had been hearing babies cry 
at night when she knew logically that there were no 
babies around. She admitted that she had had a 
therapeutic abortion; her sister had given birth to a 
child the month prior to the visit. The time at which the 
patient began to hear "babies cry" was exactly when 
she found that her sister was pregnant! 

This patient was not psychotic, and the crying noises 
she was hearing were not auditory hallucinations. In- 
stead, the noises represented wish-fulfilling fantasies; 
that is, she very much wanted a baby and hearing the 
baby cry was a psychological attempt to have her baby 
present. Further, the crying noises were an attempt at 
restitution and undoing. 



Discussion 

Our work leads us to believe that there are, in some 
cases, emotional sequelae to therapeutic abortion. 
While the vast majority of women can undergo the pro- 
cedure without difficulty, some patients are at risk for 
developing emotional conflict following abortion. Our 
experience is at variance with the earlier literature in 
which it is noted that there are minimal, if any, seque- 
lae to therapeutic abortion. We suggest that the 
emotional impact of abortion should be considered in 
any woman who develops emotional symptoms follow- 
ing abortion, even if the time interval is several years. 



References 

1. U.S. Medicine, 15 Nov, 1978, p 2. 

2. Patt SL, Rappaport RG, Barglow P: Follow-up of therapeutic 
abortion. Arch Gen Psychiatry 20:408-411, 1969. 

3. Ewing JA, Rouse BA: Therapeutic abortion and a prior psy- 
chiatric history. Amer J Psychiatry 130:37-40, 1973. 

4. Osofsky JD. Osofsky HJ: The psychological reactions of pa- 
tients to legalized abortion. Amer J Orthopsychiatry 42:48-60, 1972. 

5. Werman DS, Raft D: Some psychiatric problems related to 
therapeutic abortion. NC Med J 34:274-275, 1973. 

6. Spaulding JG, Cavenar JO Jr: Psychoses following therapeutic 
abortion. Amer J Psychiatry 135:364-365, 1978. 

7. Cavenar JO Jr, Maltbie AA, Sullivan JL: Psychiatric sequelae 
of therapeutic abortions. NC Med J 39:101-104, 1978. 

8. Cavenar JO Jr. Maltbie AA, Sullivan JL: Aftermath of abor- 
tion: anniversary depressions and abdominal pain. Bull Menninger 
Clinic 42:433-438, 1978. 

9. Cavenar JO Jr, Maltbie AA, Hammett EB: Anniversary reac- 
tions: an easily overlooked clinical phenomenon. US Nav Med 69:18- 
21. 1978. 



Project Handclasp 



The U.S. military has always 
been involved in humanitarian 
endeavors throughout the world, 
particularly during periods of 
catastrophe and devastation. The 
Navy*s Project Handclasp was 
conceived as a military humani- 
tarian program, officially recog- 
nized, on a full-time basis. This 
people-to-people program is a 
way in which our servicemen can 



help our less fortunate neigh- 
bors. 

The mission of Project Hand- 
clasp is to provide overseas com- 
mands, fleet units, and Navy 
ships with the humanitarian 
materials essential to carry out 
peace-building and nation-build- 
ing as American ambassadors of 
goodwill. 

Handclasp is a program the 



entire Navy can take pride in and 
one the Medical, Dental, Nurse, 
and Medical Service Corps might 
wish to become more involved in. 
For further information, contact 
CDR M.C. Tevelson, West Coast 
Director, Project Handclasp, C/O 
Headquarter Eleventh Naval Dis- 
trict, San Diego, Calif. 92132 or 
call (714) 235-3438, Autovon 933- 
8438. 



Volume 70, April 1979 



25 



A Critical Look at Margin Placement 
in Restorative Dentistry 



LT Bert W. Winterholler, DC, USNR 



The response of gingival tissues to the accumulation 
of bacterial plaque on tooth surfaces is now well 
documented and the role of microorganisms in 
dental and periodontal disease established fact. Much 
current research is directed toward determining the 
identity of substances produced by plaque which induce 
the inflammatory changes seen in acute and chronic 
periodontal disease and until the discovery of the 
mechanisms involved in these changes, accepted 
therapy will initially include the elimination of local 
factors such as plaque, supra- and subgingival calculus, 
decay, inadequate restorations, roughened root sur- 
faces, etc. All of these are known to arrest and possibly 
eliminate the progress of periodontal disease. The 
fabrication of restorations which result in the placement 
of margins at or below the free gingival margin has 
been implicated as a contributing factor in the initiation 
and existence of chronic periodontal inflammation and 
perhaps the apical migration of attachment epithelium 
with corresponding pathologic pocket formation (1-3). 
Even those restorations which have been done to the 
best of human tolerances will result in a discrepancy at 
the tooth-margin interface which is plaque retentive 
and which will result in the permanent exposure of 
adjacent gingival tissues to the products of microbial 
plaque. Recent studies have attempted to establish 
whether this phenomenon is the result of purely me- 
chanical irritation to the gingival cuff by the margins 
themselves or a result of the plaque retentive nature of 
margins, or both (4,5). There does not appear to be a 
definitive answer to this question from current research 
but the latter concept is favored. That is, the plaque 
retentive nature of the margins along with the surface 
of the material of the restoration, whether of fixed 
prosthetic appliances or otherwise, often results in 
long-term, slowly progressing periodontal disease. 

Restorative procedures, and the prosthetic replace- 
ment of teeth with fixed bridgework, regardless of the 



From NRMC Portsmouth. Va. 23708. 



expertise with which they are accomplished, result in 
some form of compromise to the natural unviolated 
enamel, or root surface of a tooth. It is fortunate in- 
deed, that restorative intervention to arrest and prevent 
development of further dental disease is as well tol- 
erated as it is, by the periodontium. Waerhaug and 
others in studies dealing with the periodontal response 
to various restorative materials, have demonstrated 
that the surfaces of these materials do not approximate 
the surface of unviolated enamel in smoothness or tex- 
ture and have implicated the plaque retentive nature of 
even highly glazed or polished surfaces as potential 
causative factors in the chronic inflammatory process 
found adjacent to restorations placed below the free 
gingival margins in otherwise periodontally uninvolved 
or only minimally involved subjects (6,7). Frank et al 
have shown that this inflammatory lesion is associated 
with the subgingival areas of Class V gold foil restora- 
tions but not evident adjacent to condensed gold foil 
placed below the level of the epithelial attachment (8). 
Hence the conclusion that the lesion is not the result of 
a foreign body reaction to the material itself, but rather 
the result of the accumulation of plaque at the tooth- 
margin interface or on the surface of the material. Fur- 
ther studies by Lorato to investigate the relationship 
between pocket depth and the concommitant existence 
of subgingival crown margins has shown that of those 
teeth examined which had full cast gold crowns with 
cervical margins finished at or above the free gingival 
margin, 79% were surrounded by clinically normal 
gingiva, but of those examined which had cast gold 
crowns with cervical margins placed subgingivally, 
adjacent tissues exhibited characteristic signs of 
chronic inflammation in 80% of the cases (9). Lorato 
further demonstrated a statistically significant correla- 
tion between the greater pocket depth found adjacent to 
teeth with cast crowns versus pocket depths adjacent to 
unrestored teeth. In studies conducted at the Veteran's 
Administration Hospital in Denver, Colo., it was found 
that of teeth restored with crowns having subgingival 
margins, over half were associated with pathologic 



26 



U.S. Navy Medicine 



pocket depths when compared to non-restored teeth. It 
would be expected that in those patients exercising an 
adequate level of oral hygiene, there would be less 
tendency for the development of periodontal pocketing. 
However, there was no positive relationship found be- 
tween the frequency of oral hygiene and pocket depth 
adjacent to crowned teeth (10). 

It appears, therefore, that the decision to place the 
margins of a restoration subgingivally is one which 
should be made only after conscientious consideration 
of factors influencing the need for restoration of the 
tooth and those which will affect the health of the tooth 
and its supporting structures after final placement or 
cementation. Since fixed prosthetics are often accom- 
plished in the presence of concommitant periodontal 
compromise, it would be well to consider the role which 
placement of subgingival margins may have on the 
periodontium. 



The first and perhaps foremost consideration is that 
of patient cooperation in achieving a satisfactory 
level of routine oral hygiene in order to prevent the 
occurrence of periodontal disease or deterioration of 
already existing controlled pathology. Too little 
emphasis is placed on this aspect of maintenance be- 
fore and after placement of fixed restorations. The pri- 
mary responsibility for maintenance of periodontal 
health rests not with the dentist but with the patient. 
When fixed prosthetics are placed, the patient must be 
given adequate instruction and guidance to maintain 
optimum oral hygiene. The patient must be made to 
understand that the placement of any restoration in his 
dentition, expecially in "replacement" prosthetics, 
where one or more teeth are missing and to be restored, 
will require additional effort and more effective home 
and professional care before, during, and subsequent 
to completion of treatment. Too many patients are led 
to believe that "caps" and "bridgework" are the ulti- 
mate restoration which will restore esthetics and func- 
tion without understanding that they will additionally 
require more care. Implicit in the treatment of any pa- 
tient is the need for a comprehensive treatment plan 
which must include preventive counseling prior to the 
initiation of definitive restorative care and in those pa- 
tients requiring fixed prosthetics, additional instruction 
in the specific hygiene requirements of such restora- 
tions. 

The esthetic requirements of fixed prosthetics are 
obviously divided categorically into anterior, posterior, 
maxillary versus mandibular, and buccal-lingual de- 
mands. If undue esthetic compromise would result if 
supragingival margins were employed, whether the 



restoration be anterior or posterior, then margin place- 
ment would conform to these requirements. Occasion- 
ally, it becomes more reasonable to fabricate appliances 
with margins finished supragingivally in mandibular 
anterior crown and bridge restorations if the margins 
can be terminated on sound uninvolved enamel. Doing 
this provides the operator direct access to finish, 
smooth and polish the margins, and provides the pa- 
tient access to directly visualize the surfaces for plaque 
removal and maintenance. 



In abutment teeth or piers which have been worn 
extensively due to occlusal wear or attrition or 
where crown to root ratio favors an occlusogingivally 
longer crown preparation to gain favorable retentive 
characteristics for the fixed appliance, subgingival 
margins may be unavoidable. In those instances where 
already present amalgam or other restorations extend 
subgingivally, or where cervical decay and/or decalcifi- 
cation exists, it is judicious to extend the margins of the 
crown apical to the existing restorations. If, however, 
esthetic, retentive, and strength requirements can be 
met without undue compromise, then supragingival 
margins should be given every consideration in plan- 
ning the restoration. Preparation of the teeth, taking of 
impressions, fabrication of temporaries, minimal 
gingival trauma during preparation and retraction, 
direct access to the margins by both dentist and patient 
are but a few of the advantages of the supragingival 
margin. Moreover, research has demonstrated that 
enamel is the smoothest and most acceptable surface in 
the mouth to which all natural and restored surfaces 
should be compared (11). As has been previously 
stated, even the surface of glazed porcelain does not 
approach enamel in texture or smoothness. In view of 
this information, it seems prudent that subgingival 
margins be done only if specifically indicated and not 
simply out of habit. 



Conclusion 

The matter of margin placement in restorative den- 
tistry does not have well defined parameters which are 
universally applicable. Treatment planning and prepa- 
ration of restorations should, be done with a rational 
approach to dental and periodontal health. The concept 
of preventive dentistry does not and should not end 
with simply the prevention of decay and periodontal 
disease in the healthy individual, but must be extended 
to include those patients in need of restorative care or 
who already have extensive restorative work present. 



Volume 70, April 1979 



27 



References 



1. Marcum JS: The effect of crown margin depth on gingival 
tissue. J Prosth Dent 17:479-487, 1967. 

2. Lorato DC: Effect of cervical margins on gingiva. J Calif Dent 
Assoc 45:19-22, 1969. 

3. Lorato DC: The effect of crown margin extension on gingival 
inflammation. J South Calif Dent Assoc 37:476-478, 1969. 

4. Karlsen K: Gingiva) reactions to dental restorations. Acta 
Odontol Scand 28:895-904, 1970. 

5. Volchansky A: A comparative study of natural and restored 
surfaces of teeth adjacent to the gingival margins. J Dent Res 52:609, 
1972. 



6. Waerhaug J: Effect of rough surfaces upon gingival tissues. J 
Dent Res 35:323-325, 1956. 

7. Volchansky AP, Cleaton-Jones, Relief DH: Study of surface 
characteristics of natural teeth and restorations adjacent to gingiva. J 
Prosth Dent 31:411-420, 1974. 

8. Frank RM, Brion M, DeRouffignac M: Ultrastructural gingival 
reactions to gold foil restorations. J Prosth Dent 46:614-624, 1975. 

9. Lorato DC: Effects of artificial crown margin extension and 
tooth brushing frequency on gingival pocket depth. J Prosth Dent 
34:640-643, 1975. 

10. Ibid. 

11. Volchansky AP, Cleaton-Jones, Retief DH: Study of surface 
characteristics of natural teeth and restorations adjacent to gingiva. J 
Prosth Dent 31:411-420, 1974. 



Aviation Medicine at the National 
Library of Medicine 



A unique display of historic literature relating to 
aerospace medicine is on display at the National Library 
of Medicine in Bethesda, Md. through 18 May. The 
exhibit was developed in cooperation with the Aero- 
space Medical Association which holds its 50th anniver- 
sary meeting in Washington 14-17 May. 

One item of particular interest is a book entitled Nar- 
rative of Two Aerial Voyages published in 1786. The 
book, written by Boston physician Dr. John Jeffries, 
recounts his famous 1785 England to France balloon 
voyage with the eminent French aeronaut, Jean Pierre 
Blanchard. The flight, reputed to be the very first over- 
water flight, was ostensibly undertaken for scientific 
purposes. 

Some of Jeffries clothing worn on the flight is also 
displayed. The rest of what he wore that day was jetti- 
soned as ballast when the flight almost ended prema- 
turely in the English Channel. 

The exhibit features other works such as La Pression 
Barometrique (1878), a study of altitude sickness, Louis 
H. Bauer's Aviation Medicine (1926), and a work by the 
same title (1939) by Harry G. Armstrong. Armstrong's 
work became the basis for Germany's highly developed 
aviation medicine program in World War II. 

There are books on war neuroses and combat fatigue 
in flight personnel, and two classics by Ross McFarland 
— Human Factors in Air Transport Design (1946) and 
Human Factors in Air Transportation (1953). 

The NLM exhibit brings us into the space age with 
Principles of Bioastronautics, Siegried Gerathewohl's 
1963 study of the medical implications of space flight. 




Dr. John Jeffries at the time of his historic transchannel 
balloon crossing in 1785. From the frontispiece of Narrative 
of Two Aerial Voyages. 



28 



U.S. Navy Medicine 



BUMED SITREP 



FMF MEDICAL SUPPORT 

The Medical Officer, U.S. Marine Corps will convene 
the Fourth annual "Conference of Selected Medical 
Department Officers of Marine Corps Commands" 
during the period of 16-20 April 1979. This conference 
will focus on matters pertaining to overall medical sup- 
port for the Fleet Marine Forces. Specific topics and 
agenda items are currently being solicited. A command 
Master Chief symposium is proposed for the same time 
frame. For additional information contact the Medical 
Officer's Office, Headquarters U.S. Marine Corps, 
Autovon 224-4477 or Commercial (202) 694-4477/1499. 



CHAMPUS HANDBOOK BEING DISTRIBUTED 

A mass printing of the CHAMPUS Handbook for 
Beneficiaries has been completed and the initial steps 
have been taken to place it in service distribution chan- 
nels, according to DOD officials. 

The officials note that it will be several weeks before 
the 92-page booklet will be available through CHAMP- 
US Advisors/Health Benefits Advisors, CHAMPUS 
Contractors, and OC HAM PUS. They add that copies 
are being mailed to retiree families. 

The handbook summarizes who is eligible for 
CHAMPUS benefits, the extent of benefits, circum- 
stances under which the benefits are available, how to 
claim benefits, and other pertinent information about 
the entire program. 

A limited quantity of the publication was distributed 
last summer to selected individuals who asked to 
evaluate its readability and content. CHAMPUS offi- 
cials anticipate that every family which is eligible for 
the program will receive a copy of the current printing. 



NEW CHAMPUS CONTRACTOR FOR SIX STATES 
AND CHRISTIAN SCffiNCE CLAIMS 

Beginning 1 March 1979, CHAMPUS/CHAMPVA 
claims for professional and institutional care provided 
in Massachusetts, New Hampshire, Connecticut, 
Maine, Vermont, and Michigan must be filed with Blue 
Shield of California. 

All CHAMPUS/CHAMPVA claims for Christian 
Science services provided anywhere in the world must 
be filed with the same organization, beginning on the 
same date. 



Blue Shield of California has been selected to process 
CHAMPUS/CHAMPVA claims from the six states on 
the basis of recent competitive bidding. The California 
organization replaces Blue Cross/Blue Shield of Mas- 
sachusetts as the contractor for Christian Science 
claims and for claims from Massachusetts, New 
Hampshire, Connecticut, Maine, and Vermont. It re- 
places Blue Cross and Blue Shield of Michigan as the 
contractor for Michigan. 

Affected beneficiaries should begin submitting 
claims to the new contractor after 28 Feb 1979, even for 
care and services received before that date. 

Claims for professional and institutional care re- 
ceived in Michigan should be sent to: Blue Shield of 
California, P.O. Box 85116, San Diego, Calif. 92138. In- 
quiries concerning Michigan claims submitted prior to 
1 March 1979, should be sent to: Blue Cross and Blue 
Shield of Michigan, 600 Lafayette East, Detroit, Mich. 
48226. 

Beginning 1 March, claims for care received in the 
other five affected states should be sent to: Blue Shield 
of California, P.O. Box 85117, San Diego, Calif. 92138. 
All Christian Science claims should be sent to: Blue 
Shield of California, P.O. Box 85035, San Diego, Calif. 
92138. 

Inquiries concerning claims submitted to Blue Cross/ 
Blue Shield of Massachusetts prior to 1 March should 
be referred to that organization. The address is P.O. 
Box 1520, Boston, Mass. 02102. 



CHAMPUS EXTENDS COVERAGE FOR 
SERVICE-CONNECTED CONDITIONS 

CHAMPUS coverage for retirees with military ser- 
vice-connected injuries and illnesses has been extended 
for an additional year — through 1979 — according to 
CHAMPUS officials. 

The CHAMPUS Regulation, 6010.8-R, currently ex- 
cludes coverage for service-connected conditions since 
this medical care is provided under a program adminis- 
tered by the Veterans Administration. However, imple- 
mentation of this exclusion was delayed until 31 Dec 
1978, while Congress considered several bills which 
would eliminate the exclusion. 

Pending congressional action, implementation of the 
exclusion is now delayed until 1 Jan 1980. 



Volume 70, April 1979 



29 



■frU.S. GOVERNMENT PRINTING OFFICE: 



1979 2 61 %71 



U.S. NAVAL PUBLICATIONS and FORMS CENTER 
ATTN: CODE 306 
5801 Tabor Avenue 
Philadelphia, Pa. 19120 



POSTAGE AND FEES PAID 

DEPARTMENT OF THE NAVY 

DoD-316 




Official Business 



CONTROLLED CIRCULATION RATE 



SUBSCRIPTIONS AVAILABLE 



U.S. NAVY MEDICINE is now available by sub- 
scription. Supporters of Navy medicine who are not 
eligible for free distribution, or who want their copy 
sent to their home address may order a personal 



subscription through the U.S. Government Printing 
Office. Subscription rates are $11 per year (12 is- 
sues) to addresses within the U.S., and $14 per year 
to foreign addresses. 



Enter my subscription to U.S. NAVY MEDICINE.— $11.00 domestic mailing— $14.00 foreign 
mailing. (Subscription rates include postage and handling costs. Make checks payable to 
Superintendent of Documents.} 



Send Subscription to: 












NAME— FIRST, LAST 


COMPANY 


NAME OR ADDITIONAL ADDRESS LINE 


1 1 1 1 


STREET ADDRESS 

! 1 1 II I 1 1 1 1 1 1 II 1 


1 1 1 1 


CITY 




STATE 




ZIP CODE 



MAIL SUBSCRIPTION FORM TO: 
Assistant Public Printer 
(Superintendent of Documents) 
Government Printing Office 
Washington, DC 20402 



PLEASE PRINT 



U.S. NAVY MEDICINE